LEONARD TUSHNET, M.D. THE MEDICINE MEN $2 The Myth of Quality Medical Care
in America Today Reprinted in full from the hardcover edition. ~l THE MEDICINE MEN The
Myth of Quality Medical Care in America Today LEONARD TUSHNET, M.D. Contents I
Mirror, Mirror On the Wall I II The Visitation
7 III The Name of the Rose 9 IV The
Sacred Precincts
14 V History and Physical 17 VI The Oracles
18 VII A Commercial
Note 24 VIII Members of One Body
25 IX The Pow-Wow 51 x In The Medical Staff
Lounge
~3 XI The Bubbling Cauldron
54 XII Advice From an Infidel
60
Copyright 1971 by Leonard Tushnet ALL RIGHTS RESERVED Library of Congress
Catalogue #78-166194 Manufactured in the United States of America No part of this book may
be reproduced without permission in writing from the publisher. Reprinted by CONSUMER
EDUCATION RESEARCH GROUP under special arrangement with St. Martin's Press
Mirror, Mirror on the Wall
"It is as fatal as it is cowardly to blink facts because they are not to
our taste."
-John Tyndall, Science and Man
The purpose of this book is to give you a candid look at the practice of
medicine and some of its practitioners in America today. It is a view from
the inside. Doy~t get the idea, however, that it will be an attack on a
Noble Profession. It won't be. Not unless the truth can be construed as an
attack. This will not be an expose' of the horrors committed in the name
of science-I leave that to the philosophers and the antivivisection
societies. Neither will it be a Sickroom Confidential written under an
assumed name to protect the guilty-that belongs to Doctors, X Y and Z. Nor
will it be the Maria Monkish inside story of what goes on behind the
closed doors of the consulting room-that's for the lady novelists and
Hollywood.
I merely hold the mirror up to nature. De te, fabula
-which is a fancy way of saying, "Here you are. Take a good look, and what
are you going to do about it?"
Because this book is not only about doctors. It's about their patients,
too. Without the latter the former couldn't ride around in Cadillacs (or,
if they are rich enough and no longer feel the need to impress their
patients, in tiny cheap foreign cars). They couldn't afford the long
vacations to Europe and the cruises to Bermuda and the expensive country
clubs and the private schools for their children and the multiple-carat
diamond rings for their wives. The laborer is worthy of his hire and when
be works he should get paid, but once in a while his employer might ask
himself, "Am I getting my money's worth? Do I really need this guy around?
Can't I get along without him?"
Sure, he (and you) can-to some extent. It would be a good thing for the
doctors, too. They'd spend less time worrying about the stock market and
how to cir
2
The Medicine Men
cumvent government-supervised medicine and they'd have more time to
enlarge their souls by contemplating exactly what they're doing-and why.
Not that doctors are any more venal than the rest of the population; on
the whole they're less so, but they're more conspicuous.
I said-to some extent. You can't get along entirely without doctors. You
need one when your child has a high fever, when you've broken a leg, when
your wife has a bellyache-but you don't need a doctor because it's the
style to have one. You need a doctor the same as you need a plumber for
stopped-up drains, a roofer for a leaky roof, or a television repair man
for snow on the screen. You need him as you need any skilled craftsman.
Which means that you don't need one who carries out a mystic ritual in
pompous regalia, who hides his mental indolence under the mask of science,
who struts like a god amongst mere humans.
I'm in a position to talk about doctors, a better position than that of
the medical bureaucrats or the social reformers. I had a sound medical
education at University and Bellevue Hospital Medical College, and I was a
general practitioner, a family doctor who actually made house calls for
tli-irty-five years. I started my practice in a typical American working
class neighborhood: Germans, Poles, Jews, Ukrainians, Italians and Irish.
The neighborhood slowly changed: echt Amerikaners, Negroes, began to move
in and the others moved out. My practice changed, too. From treating
workingmen and their families I graduated, because the next generation had
greater opportunities, to treating white-collar workers and junior
executives, and then their bosses. I have had a real millionaire as a
patient plus a few semimillionaires. I've been paid by Emergency Relief
chits, welfare slips, Medicare forms, good and bad checks, and best of
all, by cash. You might say (if you don't mind that eloquent clich6-I've
nothing against cliche's because they're great timesavers: they prevent
wear and tear on the brain) that my patients ran (puffed, grunted, or
wheezed) the gamut from very rich to very poor. One thing they had in
common. They were sick, and they reacted to sickness in the same way, not
even mutatis mutandis, which I'm not going to bother to translate. Look it
up if you want to. You might as well learn some Latin so you'll be one up
on your doctor. Contrary to common opinion, he knows little of that
classic language.
I have lived through the days when pneumonia was treated by serum when it
was available, and when it was not, by the liberal use of mustard
plasters, expectorants, and prayers to St. Jude. Plus diligent watching,
of course. You remember that Sir Luke Fildes painting, "The Doctor"?
You've probably seen a steel engraving of it in your doctor's office. It
shows a sentimental scene: a bearded doctor N,,ith top liat and wing couar
is holding his chin in contemplation of a sleeping (or dying) child lying
on an inipron-ised I)ed made of two chairs, while the father looks %acantly hopeful at the doctor and pats his wife's shoulder. I have often
wondered what the doctor is thinking about. Certainly not about the
comfort of the child restiiig on those backbreaking chairs. Nor about the
%-altie of the medicine he's just given, because if the child has
diphtheria or pneumonia or any other likeln- illness, he knows the
medicine didn't do any goocl. 1'%-e come to the conclusion that the doctor
is just -,%-atcliiiig, watching being standard in Victorian medical
rittial.
I was on the scene when sulfanilamide turned pa,tients blue, antibiotics
gave them uncontrollable diarrhea, and cortisone changed skiiiii-,- N-.omen into florid elephants. I have observed plastic surgery become
respectable and syphilis mentionable. I have seen appendectomies go out of
style, titerine suspensions frowned on, and focal infections poohpoohed,
and I have seen new fads take their place: hysterectomies, lumbar
sympathectomies for the treatment of high blood pressure, and heart
val,~,e stirger,%-.
So what does all that prove? That I lived a long time? That as a result of
delivering babies, N,,riting prescriptioiis for nervous stomachs, and
opening boils I have become a I)eiiign Old Doc willing to gin-e the
benefit of his experience to a bunch of opeiiniotithed neophytes
(patiei)ts as well as doctors)? No. The great patliologist Virchow once
said that some doctors make the saiite mistake for twenty years and call
that experience. Not me. You get along the best N-,-aN- you can. All I'm
trying to do in this book is tell %-oti the facts. The rest is lip to you.
Don't get the idea that I'm a disgruntled hack who couldn't make a living
in the practice of medicine and who now hollers that the grapes NN-ere
sotir and who wanted them aiix,waN~? Not at all. I have retired (amidst
the tears of my patients) to live on an adequate income derin,ed from my
practice. A little whisper-my fees slowly climbed from two dollars for an
office visit to a magnificent fi\,e, and from three dollars to six for
house calls (I made them!). I am a living demonstration that a doctor can
get rich according to the laws of classical economics when a huge demand
exceeds a very limited supply.
There's very little advice in this book. It is strictly
.%I fryL'Pf At irror on the %%'all
infoc-,iti,-,tial, the information having been distilled
n%
and .-otir, blood, sweat, tears, urine, sputum ~-Aher more or less
unmentionable exereta. My hope -on %,
ttlat % -ill use the information to become an educ.ated consumer, to
become less credulous of what doctors sa%-. and to become a disbeliever in
the doctrine of medical infallibility.
1-,x)k iii the niirror of medical practice. See what's there Niax-I)e the
next time your hand gets the itch to
,-otir pet phvsician you'll put calamine lotion on .t iTi(! (to something
more excitiiag, like makii-ig love or (liml)iniz a mountain. Maybe the
next time you visit N otir (I(x:tor, %-ou'll look at him with eyes
unclouded bv Afft-t tioii and with the skepticism of one who no loi-iger
!wlie%es in magic you'll think about what he proposes to do
No scieiitific discussion would be complete without (IiNtr,t(.-tiiig
footnotes. Those you'll find in this I)ook are ;,-)r the iiidiniduals who
can't possibly believe the refleetioii in the mirror. There are also
digressions, mostly for fun. And a number of anecdotes. Doctors love
aiiecdotes. Some are sad, some are hilarious, but always, always they're
true.
-Now i)roceed to your medical educatioi-i.
2.
First let's take a very broad view of what medical practice is supposed to
do, then zoom in on what it actually does, and then look at close-ups of
what happens when you're sick. Because, after all, you are not a
statistic. You are a human being with hands, organs, dimensions, senses,
affections, passions. You want to know what's the best that can be done
for you and %%-bo's going to do that best. As a citizen of the richest
democracy in the world, yoi-i're entitled to know that. Regardless of your
wishes, from the remote vantage point of the demographer you are part of
his statistics. So--let's see how you fare in that role.
Since we are the richest nation in the world, it fol1,)\N-s that the
United States of America should have the fii-iest technology and the most
advanced sciences. We should be able to afford the best of everything, no
matter %%-hat the cost. We should have the best medical men in the world.
It certainly looks that way. Foreign graduates in medicine flock to our
hospitals and to our training centers to learn the latest techniques of
diagnosis and treatment. Our pharmaceutical companies have branches all
over the globe. With all the advan
3
tages money can buy we should be the healthiest nation in the world.
Right? Wrong!
Truth is stranger than fiction, but not so popular. We're spending the
money, all right. In 1937 the budget of the National Institute of Health
included less than $150,000 for subsidies of biomedical research in
university hospitals. Ten years later that figure rose to a million
dollars. In 1965 more than a billion dollars was distributed in support of
medical research. From 1937 to 1967 the cost of the intramural research
program of the National Institute of Health alone rose from about $350,000
to ninety million dollars. Besides that, nonfederal support of medical
research increased ten times since the end of World War 11. The total
consumer spending on health care soared from $19.1 billion in 1960 to
$31.3 billion in 1966. It went up to $42.6 billion in 1969, according to
the Office of Business Economics of the U.S. Department of Commerce. As a
nation we're not stingy-that's for sure-when it comes to laying out money
for our health. What have we got to show for all that cash?
Not too much. For the past two decades there has been a steady leveling
off in actual health progress, maybe even a slight deterioration in
comparison with the rest of the world. The life expectancy at birth for
niales was 66.6 years in 1959; in 1970 it was 67.0 years. Ditring those
eleven years we dropped from thirteenth to twenty-second on the world Est.
Norway's rate went tip to 71.4 in the same time, and Canada's from 67.4 to
68.4. In this country the life expectancy of females rose from 72.7 years
to 74.2, but women did 13etter throughout the rest of the world; we barely
managed to hold on to seventh place. Actually, a man of forty can expect
to live only about four years longer than did his grandfather in 1900; a
man of sixty can anticipate only an added year and a half over what he
coul(I have lived in 1900. Furthermore, there is no way of de --rmining
how much of even this small gain is due to better medical care or to
improvement in housing, sanitation, and general living standards.
A mathematical paradox is hidden in the statistics. The saving of infants
from exhausting diarrhea and the prevention of death from diphtheria in
small children will add years to a longevity table but not to the life of
a grown man. For example, a male child born today has a chance of living
191,/, years longer than if he were born in 1900, but a man of forty today
might live only eight years longer than if he were forty in 1900.
The World Health Organization of the United Nations gives the death rate
per 100,000 persons (from
4
The Medicine Men
disease only) in the United States as 85.8 in 1965, an increase over the
83.7 in 1963. We lag behind Japan, Northern Ireland, Yugoslavia and
Greece-all not very rich countries-but at least we're ahead of Colombia
and the Philippines. If we take one disease by itselfcancer of the skin,
for example-in England the rate per 100,000 persons dropped from 21.4 to
19.3, but in the United States it rose from 22.1 to 23.5 in the same
period (1955 to 1964). And if we look at how we are caring for our
mentally ill children, the picture is even worse. The National Institute
of Health reports that in the year 1966 (the last year for which accurate
reports are available) 1,400,000 children needed psychiatric care, but
fewer than 500,000-about a thirdreceived it. That's enough for statistics.
If you want more or want to check on mine, I refer you to Dr. David M.
Rutstein's book, The Coming Revolution in Medicine, Cambridge, 1967.
What does a little sober reflection demonstrate? For one thing, maybe it's
not the amount of money the country spends on health that's important. The
Pharoahs poured gold and silver into the building of the pyramids, and
their engineering feats were marvelous, but to what end? In 1910, a
medical joke (?) goes, a patient had a fifty-fifty chance of benefiting by
seeing a doctor. Is he much better off today? The tools of the medical
trade are finer, the conjurations more logical and the herbs tastier, but
the approach of death seems to be about as fast. In this country the
majority of men do not reach even the Biblical three-score-and-ten. Maybe
it's time to see if we're getting full value for our money. Maybe we ought
to get rid of our comfortable misconceptions about how well our doctors
treat us.
First, let's get rid of some of our nationalistic arrogance. Wealth is
not a necessary companion of wisdom. American biologists did not discover
penicillin-an Englishman did. American engineers did not develop the
artificial kidney-a Dutchman did. American chemists did not synthesize the
phenothiazines-a Frenchman did. I have no desire to denigrate the
accomplishments of American science. I merely state the facts. Necessity
may be the mother of invention, but money is certainly no relation.
Millions of dollars are raised here(not counting the tax money spent for
the same purpose) for research, prevention and treatment of a dozen or
more diseases by private foundations. Of the oldest, the National
Tuberculosis Association, one weH known doctor has noted that "the sad
fact remains that the National Tuberculosis Association has contributed
relatively lit
tle to the fight against tuberculosis."' According to him, the public is
deluded when it thinks that its massive contributions have any substantial
effect on the control or alleviation of muscular dystrophy, cystic
fibrosis, or any of the other diseases used for fund raising. The full
details, for example, of the Salk vaccine fiasco can be found in Dr.
LaSagna's book on page 150. After the general use of the Sabin vaccine and
the virtual disappearance of poliomyelitis from the United States, did the
polio foundation fold up? No, sir. It changed its name and its purpose-to
research in arthritis and birth defects. Old foundations evidently don't
die; they merely metamorphose themselves. The amount of money the
foundations collect and spend is far out of proportion to the good they
do. To ask for more money is to make the assumption that lack of funds is
the only bottleneck in research. That is not trite. It is the dearth of
fruitful ideas that's the trouble.
And remember that the heavy hand of entrenched blireatieracy is
strengthened by the lifting of moneybags. For example, the possibility of
a viral cause for cancer was pooh-poohed for years because of the bias of
pathologists that cancer was a single disease sui generis. Since
pathologists, the doctors who -make microscopic studies of tissues, were
the final arbiters in the sttidy of cancer, it took a long time to
overcome their influence. Today most researchers into cancer have come to
agree that the answer to the cancer problem may lie in the field of
immunization to that dread disease. Pouring money into specific areas of
research is not necessarily the way to stay healthy. Witness the cool
response of responsible scientists to President Nixon's proposal for a
Manhattan Project against cancer.
Another wasteful expenditure is the proliferation of highly specialized
medical agencies. Hyperbaric chambers, cardiac surgery teams, and
radioactive isotope laboratories are only a few of the many services that
spring up in communities where the need for such services is very limited
and where modern transportation has done away with isolation. Although
doctors are the advisors and pushers of such projects, they are not always
the originators thereof. Citizens filled with civic pride and hospital
trustees seeking glory are partners in the crime of building and equipping
structures when similar facilities exist only a few miles down the
highway. And then, of course, it becomes necessary to in
I Dr. Louis LaSagna, The Doctor's Dilemma, Harper & Bros., New York, 1962,
p. 154.
Mirror, Mirror on the Wall
form the ,-,-orld (or at least the neighbors) about the forNN-ard-looking
hospital administration, a sure winner in the medical one-upmanship game.
So-public relations firms are hired, publicitv campaigns are started, and
ever so ethically the peopie are informed about the wonders being
performed daily at St. Moses General Hospital. If connections are good
enough, maybe a Senator or a President's wife will come for treatment -at
no cost to them, of course. The cost will be borne by the taxpayers and
the other patients. Actually the need for such facilities is sharply
limited, as low as one to a citn-, a county or even a state, in some
cases.
Too much research and too much overbuilding ii.crease the costs of medical
care but do not improve the quality of what is delivered to you. That
final stage , the direct jol) of the doctor. But a liealer implies a
patieiit to be bealed, and the relationship is dialectic, oi-ie reactiiig
on the other. I'm going to tell you about the doctors, but that means that
I'll be talking about patients, too. It takes two to tango.
Americans are used to the concepts of rapid progress and equally rapid
obsolescence. If it's new it must be better. That's why the medical
reporter is so breathless. He tries to be first w-ith the drama of every
suppo, d breakthrough (horrible word!) in the cure and pre-,,eiition of
disease. He I)tiilds t-ip folk heroes like Dr. Salk and Dr. Barnard.
Patients come to the doctor's office clutching their clippiiigs and
demanding the latest treatnieiit. "I can pay," they say, and pay they do.
Patients have the illusion that doctors are beneficent purveyors of the
best that science can offer to maintain health and cure disease. We live
in a democracy wheretheoretically all men are equal and equally entitled
to life and happiness. If there's a drug or treatment available for a
tycoon, it should be available for a tire salesman. I remember vividly a
young girl who came to me with her teenager magazine folded to the page
describing the virtues of skin abrasion for acne. The article told how
painless was the treatment, how deft were the operators and how miraculous
the results. Nothing I could say could convince her that her acne was
insignificant and didn't warrant such drastic therapy. The four pimples on
her chin and the solitary pitted mark near her right ear loomed up to her
like the landscape of the moon. Then I showed her the medical journal in
which the treatment was described in detail, together with all the
coiitraindicatioiis and possible complications. She shook her head.
"Doctor, mv Aiiiit Cecelia loaiied me four hundred dollars. What I want to
know is-do you think that will be enough?" Do you think that the treatment changed the poor self-image she had of herself? Not on your life!
Worse are the pathetic souls who have been nursing a relative with
terminal cancer. "I read in the papers that at the Mayo Ciiiiic (or the
Lahey Clinic or New York Memorial Hospital) they foui-id a new medicine
that's injected into the ve~ITs and it cures the cancer." They haven't
read that at all. They've wanted to read it and they've misinterpreted a
sometimes none-toocautious comment about current research. They borrow
money, they impoverish their families, they plague their astors until
tliev'x-e gathered together enough p
cash to make the long trip to certain disappointment. They forget tl-lat
in i-iiediciiie there are no secrets, that a new and useful therapy is
immediately adopted everywhere, that experimeiitatioi-i is not treatment.
When I was ,~oung in practice I used to get angry when I saw people
squander their savings on a will-o'-the-wisp. I thought they were stupid.
As I got older I realized that they were merely human, willing to grasp at
a straw, hoping (not really believing) that the straw was att~telied to a
strong rope that would baul them to safety. And honesty compels me to say
that now I have reached the age when I fear I bear the beating of the
,,~.-iiigs of the Angel of Death and I would probably do the same as they
did.
The doctors themselves have fostered the illusion that they have unbounded
competeiice. They have not applied their intelligence to the education of
the public -nor to themselves. They're remiss, and not because they're
moiiey-grubbers. Most of them make so much iiioiiev now that they fall
into very high income tax brac,kets and have no need to make more. They
have failed because they have come to believe ii-i their %-atinted magical
powers. They agree with the layman whose Dative optimism takes on pathos
when he enlarges on the tremendous power of medical science to do away
with pain and disease, to prolong life and to niake newer and better
drugs. The doctors see in themselves not masked medicine men treading a
mystic round, but panoplied knights standing triumphantly on the bodies of
the dragons of disease and death. It's too bad that on a close look they
resemble the knights of King Arthur's court as seen by Sir Boss:
intellectual innocents.
Witeb doctors, too, bonestly believe in their healing powers. So do their
patients. What happens where
,6
The Aledicine Men
witch doctors ply their art?
Someone falls ill. The frightened family sends a messenger entreating the
witch doctor to call. A bronze, black or yellow man in a devil mask or a
feathered headdress comes carrying the tools of his trade in a bag
(called, surprisingly enough, by the anthropologists a 11 medicine bag").
The witch doctor is a highly respected member of the community. He has
attained his exalted position by long years of study and apprenticeship.
He knows all about diseases, those caused by supernatural malevolent
forces and those caused by the patient's own bad deeds.
First, he takes a history. "Did you break any taboos? Have you had any bad
dreams? Were you fighting with your kinfolk?" While he is so engaged, his
eyes wander around the hut or the clearing to determine how many goats or
cooking utensils or turqouise bracelets the family has so that his fee
will be commensurate with its status.
He then opens his medicine bag, which contains stones, beads, shells,
1:)ones, paints, herbs and other assorted esoteric miscellany at which the
family's eyes pop open. He makes a diagnosis by divination, by the casting
of bones or the inspection of entrails or the response to the pricking of
the skiii by thorns. He sits and thinks, shakes his bead and informs the
family, "This is a hard case."
They plead with him to use his knowledge. They offer him a larger reward
than is customary. He sighs and says, "I'll try."
Therapy starts. He chants, he sings, he dances, shaking a rattle. If he is
a very renowned practitioner of the art, he has one or two assistants help
him by handing him the fetishes or the sacred sticks. He burns herbs for
fumigation to drive away evil spirits. He lets blood to eliminate poisons.
He makes mystic symbols with rootink on a piece of bark which the patient
then chews and swallows. In some cases he actually sucks out from the
patient's body the stone an enemy has caused to be there implanted.
Exhausted by his labors, be sinks back and condescends to drink some
banana wine or fermented coconut juice handed to him by the grateful
family. He gathers up his medical impedimenta, collects his fee, and
departs after giving long and complicated instructions for further
treatment.
I've made no analogy but I'm sure you already have, and just as quickly
you've suppressed that iconoclastic thought. How can you compare, you ask
yourself, the enlightened American populace to ignorant, benighted,
superstitious barbarians? Or those devoted men who minister to our health
needs to leaping grotesques in masks and feathers? It's silly, you say, to
equate a Doctor of Medicine with a Doctor of Magic. Is it so silly? Think
about it, weighing the pros and cons.
In the first place, we're smart. We know that physical ailments are not
caused by nonexistent ghosts and spirits but by equally invisible
bacteria. Mental illness is of a different nature. The Melanesian can
attribute it to a broken taboo or to divine retribution for having a
wicked soul; we know it's due to an unresolved Oedipus complex or to the
surfacing of hidden psychological conflicts. Furthermore, we place no
faith in diagnosis by conjuration or sand paintings. Our doctors use
rubber tubes with earpieces and shining instruments with lights. The poor
African has to driuk nauseating mixtures to get well; we have multicolored
capsules and pills that work in mysterious ways their wonders to perform,
Let primitive peoples rely on rites and rituals when illness strikes. More
sophisticated, we apply scientific methods. But let's not be too snotty.
Remember the mirror.
There is a superstition of faith. Certainly, a scientific education can
lead some people to find it easy to believe a number of impossible things
before breakfast, such as that men are distinguished from animals only by
the size and convolutions of the cerebral cortex or that calories don't
count or that every boy has a deep urge to rape his mother.
Let's apply some of the teachings of the cultural anthropologists to
medical practice today. Let's do as the anthropologist does when be goes
below the surface of the antics of the Bushman or the Papuan. He tries to
find out their rationale, because even primitive Stone Age people are men
endowed with reason. Their rituals are part of their attempt to control
natural processes like rain or childbirth. They dance to bring the rain;
they sacrifice a goat to ensure an easy labor. Underneath the weirdness
lies sense.
What about us? Look carefully at the mirror. How much of what we do in the
cure of disease is ritual? How much is effective? How different are we
from our brothers in Australasia?
Their medical arts are traditional. They have not varied for centuries.
Ours are constantly changing to keep up with the advances of knowledge in
the sciences. But plus ~a change, plus c'est la meme chose.
Which brings me to a description of present-day practice in America.
11
The Visitation
"The threat of a neglected cold is for doctors what
You get sick. Not terribly sick. just sick. You ache all over, your throat
feels scratchy, you have a stuffy nose, you've lost your appetite. The
ubiquitous thermometer shows you have a fevernot much, but fever's fever,
isn't it? Otherwise why do the manufacturers go to the bother of marking
those lines in red? You reach for the aspirin, but on the label, by order
of the Federal Food and Drug Administration (which will look after your
health whether or not you want it to), you read, "In case of persistent
fever, call your doctor." Not only are you patriotic and willing to do
what Washington says, you are also clever. You don't believe in patent
medicines. You're also lucky. You have a doctor and it isn't Wednesday,
Friday, Saturday or Sunday. So you can call him.
(I like that phrase believe in. It shows that Americans are not credulous
like other folk beyond the Law. This is a free country. You can believe in
or not believe in psychoanalysis, penicillin or poultices. You can believe
in blood counts and not believe in birth control pills or the other way
around. It's the American way of life. That's why orgone boxes got sold in
such quantity and why Lydia Pinkham survives only in bawdy ballads.)
The doctor comes in his big black car with the M.D. license plate and the
Aesculapian emblem. Sometimes the latter is replaced by the caduceus
because he doesn't know the difference. Snakes are snakes, aren't they?
Maybe the ' caduceus is the more accurate symbol, anyway. It's the sign of
Hermes, the god of travel, thieves and commerce.
The doctor is almost always dapper, whether he wears a sports jacket or a
black suit like an undertaker's. His costume varies according to where he
lives: the suburbs or the city. His Countess Mara tie is neatly knotted.
His shirt is gleaming white. He carries a little black bag. The size of
the bag depends on his fees: if it's big, he charges less than if it's
only a little larger than a lady's handbag. just by looking at him you
know he's competent. Why shouldn't he be? He spent four years in college,
another four in medical school, a year or two in internship, maybe three
more as a resident. After all that training he has to be good, hasn't he?
Even an airplane pilot (on whom life often depends) doesn't have that long
an apprenticeship.
The doctor stands by your bedside, disregarding the proffered chair. How
can a busy physician take time
the threat of purgatory is for priests-a gold mine."
-Nicholas de Chamfort, Pens~es
out to sit down? It's enough that he deigned to come to your house. He
listens to the recital of your symptoms until he gets bored, which doesn't
take too long. After all, what new are you telling him? He puts a
thermometer in your mouth.
He takes your pulse, looks at your eyes, reads the thermometer, shakes his
head and goes on to apply the stethoscope to your chest. Maybe he thumps
here and there. Then he says sympathetically, "It's A Virus. It's been
going around." He really is sympathetic. Doctors are very good at
sympathy. It's part of the bedside manner. Sympathy is a cheap commodity-costs absolutely nothing, as a matter of fact-so why not be generous with
it?
Phase One of the ritual has been accomplished. Now you have a rational
diagnosis, which is better than being told someone put a curse on you. By
the use of inspection, palpation, percussion and auscultation, the doctor
has brought to bear on you the full weight of the marvelous advances of
Western medicine. And be comes up with ... A Virus.
No doubt that's more dignified than a common cold. You'd feel like a fool
if you paid out your good money for just a cold. It's also far superior to
what was once fashionable-U.R.I., or upper respiratory infection. U.R.I.,
because of cultural lag, can still be found on hospital charts where the
intern's history records "Patient had U.R.I. treated by L.M.D. and
followed by S.O.B." That last abbreviation got you, didn't it? You're
wrong. It's not a pejorative characterization of the L.M.D., who is the
local medical doctor and very, very, very far down on the totem pole. It
means shortness of breath.
A Virus is guaranteed to get you more attention than U.R.I. because
everyone knows that A Virus can have many complications. And what could be
more serious than A Complication?
Now Phase Two starts. The doctor says, being of the new.school and
perfectly honest with his patients, "Of course, The Virus is a selflimited disease. You'll be better in three or four days, but just to make
sure I'll give you a prescription." The logic of his remark escapes me-not
you, because you're the patient and at the moment in your clouded state
what he says seems to make sense. But if you'll be better in three or four
days, why take any medication? And if he's not sure, what's
8
The Medicine Men
he prescribing? And for what? Don't ask. Yours not to reason why in this
day of specialized technology. The pen comes out and the little white pad
is scribbed on and the prescription is dutifully carried to the drug store
and the bottle of red-and-white, blue-and-green, or orangeand-yellow
capsules brought home. You take them. Later on I'll discuss what's in the
capsules. Don't cheat. Don't look ahead. You'll spoil the mystery.
Phase Three is important. As the doctor pockets his fee or makes a note in
his charge book, be says, "Call me if be's not better in a few days." This
is known in the lingo of the trade as covering up. It is highly
recommended in books on medical management and in journals of medical
economics. It is a talisman against potential malpractice claims. But by
that soothing remark a little anxiety is added to the family's cares. The
doctor knows more than he is telling. This Virus is nothing to be fooled
around with. Even the doctor is worried.
Not too much. When the telephone call is made, "Doctor, he still feels
weak. He has no fever but lie complains that be's tired," the doctor
calmly answers, "Now, don't worry. He'll be better tomorrow. just see that
he gets plenty of fluids, especially juices, and give him a full diet. It
was only The Virus." Did you get that only? A trivial illness, so why are
you concerned? Reassurance is so pleasant, isn't it? And Doctor's so
patient, he's an absolute angel! And you do get better, becoming a living
proof of the wonders of scientific niedicine.
Before The Virus, a cold lasted four days or ninetysix hours, depending on
the treatment. That's a real doctor joke, straight from the in-group. You
took capsules. And what was in the capsules? An antibiotic? Maybe-but
antibiotics have been shown to have no value in the curing of The Virus.
An analgesic? (Good word. Thanks to television commercials, future
generations will have no trouble distinguishing between anesthesia and
analgesia.) Aspirin's cheaper-and safer. An antihistamine? Interferes with
normal body response to infection and is potentially dangerous to
children, pregnant women and the aged.
Time out for education. Dr. Joseph Garland, in the New England Journal of
Medicine, reported on a study of 781 patients with acute infei~tiotis
illness assumed (that's exactly the word used in a reputable publication
highly regarded by physicians) to be viral in origin. The study showed
that antimicrobial agents affected neither the duration of the illness nor
the development of complications. Another study reported in the Lancet
(a British publication) that penicillin and the tetracyclines had no
advantage over aspirin in the treatment of minor respiratory infections.
In actuality, even aspirin had no effect on the course of the illness. In
an interview reported in Patient Care (August 15, 1970) Dr. Martin
McHenry, a Cleveland infectious disease specialist, recommended chicken
soup and time, not antibiotics or aspirin.
Maybe the doctor's prescription was for your comfort only and he knew well
it wouldn't cure you. Maybe he was merely trying to keep our nose from
running and your bones from acbing. Grandma did just as well, remember,
with hot tea and rum and a featherbed.
But look what you'd have niissed if you hadn't called the doctor. All that
glamour, all that ceremony, all that sympathy. You could have saved money,
but what's money compared to your health?
(While we're on the subject of the treatment of colds, here are a few
therapeutic measures I have come across in addition to the standard timefilling ones. My father used to mix a teaspoon of ca-,,enne pepper with a
double shot of whiskey. \4rs. N'erni icelli- [obviously not her right
name. You wouldn't believe the real one. It was Lemoiijello ]-varied that
b%- squeezing a clove of garlic into a glass of homemade red wine. Mrs.
Mocz dosed her children with Epsom salts in soured milk; the result kept
their minds off their colds. Mr. Schwantz swore by red flannel dipped in
vinegar and wrapped around the Deck. Mrs. Skatottlos liked horse-radish
stirred into yogurt and followed by a raw egg. I'm just telling you about
these. I never ran a double-blind control series on any of them, so I
can't say whether they were any more effectiNTe than what I used to
prescribe -aspirin, vodka and hot tea. If yoi-i want to try any one of
them, go ahead. Don't bother to let me know bow they worked. Tell your
neighbors. The~"re gettii-ig tired of that old chicken soup deal.)
Ah! you say, but a neglected cold may lead to pneumonia or something
worse. Nonsense! If you stopped to think, yot-i'd realize you know better.
Pneumonia is an infection caused by a specific germ; it has nothing to do
with the common cold. And what's neglect? It must mean not calling the
doctor, obviously, even though his treatments have no value and are purely
ritualistic. When you have the doctor "treat" a cold, you are going
through the motions of propitiating the gods. That wouldn't be so terrible
were it not for the doctor's naive belief that he's doing you good. Read
on. You'll find a chapter on what he does to you in good faith and bad
judgment.
9
The Name of the Rose
"Nor bring, to see me cease to live, Some doctor full of phrase and fame
To shake his sapient bead and give The ill he cannot cure a name."
All right. You can't blame a man for trying. After aU, who knows anything
about a common cold? But that ignorance doesn't extend to many other
areas, you're sure. Besides, what's the difference if the ailment is
called a cold or a virus?
It makes a difference. Giving a disease or any phenomenon a name is the
first step in most magic. It implies power over the unknown. It signifies
knowledge of what it is and how it is caused. Necromancers go through
elaborate rituals and end by invoking the name of the devil, who then will
be forced to give them gold, glory or Marguerites. The knowledge of the
unutterable names of God gave Solomon wisdom to understand the language of
birds and beasts. There is also a branch of medicine called nosology, the
systematic classifica
-Matthew Arnold, The Wish
tion of diseases.
Nosology has an ancient but not honorable history. The Greeks believed
that a disease was caused by an imbalance of any of the four humors:
blood, phlegm, yellow bile, black bile. (These humors described personahty
as well as pathology. From their names we get sanguine, phlegmatic,
choleric and melancholic.) By that nomination they proceeded to treatment
aimed at restoring the proper balance of the humors, mainly by diet,
exercise and exorcism, none of which helped much in cases of malaria or
typhoid fever. Later, Erasistratus taught that plethora, an excess of
blood, caused disease. He, too, used diet and exercise to reduce the
volume of blood, but his followers felt they were more logical
10
The Medicine Men
when they actually let blood. This practice returned, reinforced by
improved knowledge of the circulation of the blood, and gallons of blood
were removed in the era of bloodletting that followed. Macaulay gleefully
describes the macabre details by which King Charles 11 was medically
exsanguinated in his last illness. Most Americans are unaware of how
George Washington died--of a sore tbroat treated by emetics, purges and
the removal of four pints of blood. Still later came the development of
pathology and then the germ theory Vaccines, sera, antisepsis and asepsis
were each believed to be the definitive medical answer to disease. They
weren't, but some doctors still cling to the teaching that Corynebacterium
acnes causes adolescent acne, and others still treat that condition with
vaccines.
Now we are -in the stage where a whole class of disorders is called
degenerative, thereby implying there's not much we can do about them. For
if man is born to trouble as the sparks fly upward and death is inevitable
and hardening of the arteries an inexorable concomitant of aging, then why
beat our beads against a stone wall? Sigh and say, "It's one of those
things" when eyes grow dim and hearing fails and skin gets slack. It's
discouraging. It also gives the doctor an out. You can't expect him to
hold back time.
Naming of diseases is an important function of the doctor's ritual.
Example: You have a miserable itch at the anal area. You scratch, which is
about all you can do, considering how invisible that part of your anatomy
is to you unless you're a Japanese acrobat. You worry that you have cancer
or something equally horrendous. You shed your false modesty and in
desperation go to the doctor (who may be a dermatologist or a
proctologist, depending on your psychological background). He examines
that very private place and tells you, "You have a condition called
priiritus ani," and he outlines a course of treatment. One thing I can
guarantee youhe's 100~'c right in his diagnosis and no gambler would take
odds that he isn't. Pruritus ani means itching at the anus. Check it in
the dictionary if you don't believe me.
Another example: Your child had a sore throat and now has swollen glands
in the neck. Being a good parent, you hasten with him to the pediatrician,
who says, "Don't worry. It's only cervical adenitis." You could hug him
for that reassuring bit of information! And to think he made the diagnosis
without even a blood count! Only if you're a suspicious, subversive
character would you wonder what that is, and you would- look that up, too,
when you get home. Provided you can
spell it, that is. If you did that little bit of research you
would find that cervical means of the neck and ad,-nitis
means inflammation of the glands. It's a good thing for the doctor that
you're an honest, loyal American.
Still another example: Ever~, now and then, after you've smoked too much
or been too excited, you've felt your heart give a sudden ]:)timp and you
swear you've felt an extra beat. You're frightened. Time's swift chariot
seems a bit closer than it should be. You make an emergency appointment
with the doctor. He listens to your heart, hems and haws, nia-,-be takes
an electrocardiographic tracing. He ponders on-er the squiggles on the
paper and then tells N'Otl, "YOLI liak-e an occasional extrasystole." You
exhale in relief that you don't have a myocardial infarction, the same as
Senator Soand-so had, who died last week. Yoti console yourself that it's
a good thing you went to the doctor,. for now that the diagnosis has been
made, xoti'll get treatment appropriate to that fearful sounding disorder.
How fortunate for the doctor that you don't know that extrasystole means
extra beat!
It seems as though words are just as good as casting the dice, and names
can be substituted for messy inquiries at a sacrificial altar.
Some doctors deny that they are being intellectually dishonest by giving a
Greek or Latin synonym for the English name of a disease and thereby
cloiining the patient. They say that they are merely using euphemisms
(like passed away for died) for the patient's comfort. Maybe so. Palsy
sounds better than paralysis, edema than dropsy, and nervoiis breakdown
than depressive psychosis. But other euphemisms make the patient's flesh
crawl just by their sound: nosocomial disease for hospital infection and
pediculosis for lousiness. And where's the psychological value of writing
or saying Hansen's disease when the explanatory leprosy is added
parenthetically?
(When I was an intern I heard a patient tell her doctor that she fell
asleep promptly and as promptly woke t-ip an hour later and then stayed
awake all night. Instead of saying, "You have insomnia," which would have
satisfied her need to have her complaint given a name, the doctor said,
"The trouble with you is that you sleep too fast. Sleep more slowly." As
we left the bedside I saw her pondering over that very reasonable answer.)
The doctor's jargon has a double purpose: to astound
and confound his patients (as in the above anecdote)
and to cover up his ignorance. Too often, alas, the sec
ond overshadows the first. By naming the disease the
The Name of the Rose
doctor deludes himself into thinking he has made a rational d;agnosis; he
can then go on with confidence to therapy-and he does.
Astounding and confounding are part of the ritual, They have therapeutic
value if you're stupid enough or trusting enough to believe that part of a
cure is obfuscation by conglomerate Greek or Latin words. Some words have
no value, however. Halitosis has lost its terrors; everyone knows what
that is. Some itises, like burs-, arthr-, and neur-, are becoming worn out
from common use. That accounts for the present popularity amongst doctors
of fibrositis and myositis. Neuralgia, too, is on the way out except in
the lower classes, but cephalalgia (made up of Greek words, meaning an
ordinary headache) is taking its place.
I said "lower classes" above. I meant it. Class distinctions exist in the
doctors' naming of diseases, just as class distinctions exist in other
life styles. ( iN,Iarxists, please note). Army officers get iii,ethritis
but enlisted men get gonorrhea. Poor patients have the wax blotcii out of
their ears but rich ones have impacted cerunieti removed. Dr. Thomas
Szasz, a maverick psychiatrist, has written extensively on the
iioiidifference between the insanity of the ordinary citizen and the
abnormal behavior of the V.I.P.
Once upon a time there was a condition called general paralysis of the
insane, or paresis; instructions for its treatment appeared in textbooks
of psychiatry. Naturally, because the name implied that the paralysis
followed the insanity, it followed that the cause lay in the insanity. Dr.
Richard von Kraff t-Ebing (you're right!-the same fellow!) said in 1877
that paresis was the result of emotional stresses and psychic factors such
as excessive intercourse (when you're on to a good thing, why give it
up?), weak nerves (known as nervozis asthenia in those days, another
example of naming), and too much striving after wealth. Other
psychiatrists, noting the frequency of the disease in actors, soldiers and
sailors, had another explanation: actors played so many roles and
impersonated so many characters that thev fiiialln, lost their own
identities and became completely confused; soldiers and sailors were
exposed to such harsh climates, foreign miseries and general hardship that
they just went crazy. In 1898 Virchow (I quoted him before, but maybe I
shouldn't have, considering what follows) vehemently attacked the idea
that paresis could be caused by syphilis. Then in 1913 Hidevo Nogucbi
demonstrated the presence of spirochetes in the brain tissue of paretics,
thus proving that paresis was a late form of syphilis and should be
A new twist on medical nomenclature for the laymen treated as such. The
misnomer, general paralysis of the is the homely touch: athlete's foot for
epidermophyto-insane, was quietly dropped.
sis, for example, and housemaid's knee for I)rel)atellar Also in the field
of psychiatry there once was a coiidi
bursitis. Of course, the patient knows that the doctor is tioii called
constitutional psychopathic personality. comforting him by using the
vulgar tongue. He also is Now there was a diagnosis. It was obviously
incurable, not fooled-good old Doc is trying to keep the ])ad I)eiiig
inborn, as the first part betokeiied, and the rest news from him. When
pressed, not too hard, Doc will indicated it was on the borderline between
mental re
tardation and frank psychosis. Gradually the name was changed to
antisocial personality, and latelv to sociopath. Dr. Henry Davidson, a
psychiatrist, recently questioned whether either name was a diagnosis or a
term of derision. "Sometimes," he wrote, "these people are unhappy or
neurotic, occasionally they are truly psychopathic, and in some cases you
get the feeling that they are just evil." The patient may be sad, mad or
bad, but the name serves its purpose-to hide the doc
tor's ignorance of the true state of affairs.
(Or sometimes to show his political preferences. Antisocial indicates
violent dissatisfaction with the best of all possible worlds, our present
society, thus putting Black Panthers, Communists, anarchists and hippie
revolutionaries in the same bag. A little extension could also include
other dissenters and nonconformists like Jeremiah, Jesus and John Adams.)
Today we still have what is called schizophrenia.
give the real name of the sickness.
(I note that I have used the word layman. Laynian
stresses the snobbish separation of the medical profession from the common
herd. Doctors think they are like the clergy, anointed and blessed, with
the power to dispense life and death. You're the layman, the poor slob who
accepts the distinction. Other professions also have their noses in the
air-teacbers, lawyers and iindertakers. )
Words clothe the doctor in more than a little brief authority; they
decorate him better than the plumes of the African wizard or the ocher of
the Australasian. Osteonmlacia is more melodious than softening of the
bones, and alopecia more euphonious than plain baldness. If the doctor
puts on such verbal trappings merely to mystify you, he does you no harm.
The danger comes when he himself pays credence to the mantras he sings.
12
Doctors confronted by a group of psychic abnormalities
gave a name to it, a name from the Greek meaning split
thinking. So if it's thinking that's at fault, why look to the body for
the cause? Keep investigating the psyche. Only after decades and decades
of no results from those investigations did research turn to the physical
processes going on in schizophrenics. Naming may have held up progress. (I
say "may have." So far there hasn't been much progress. Doctors still
"treat" the condition by a variety of methods, even by reading poetry to
the patients. ) 2
Do you remember rheumatism? It was probably a diagnosis when you were
younger, but now not even TV commercials for pain relievers mention it.
Rheumatism was a convenient catchall name for rheumatoid arthritis,
rheumatic fever, osteoarthritis, gout and a dozen more painful disorders
of the joints and muscles. Rheumatism had a standard treatment: heat,
rest, and salicylates. Only when rheumatism disintegrated into its
component verities (gout, rheumatoid arthritis, osti,oarthritis, etc.) did
treatment become more rational.
Naming saves the busy doctor's time. He doesn't have to think too hard
about what causes the troubleunless he's a researcher, and then the name
may become an ignis fatuus to lead him astray. Example: There was in my
time a disease called Hebrews' Disease. (It is a canard that the name
comes from 11 Chronicles 16: 12-13, which reads, "And in the thirty and
ninth year of his reign Asa was diseased in his feet, until his disease
was exceeding great; yet in his disease he sought not unto the Lord, but
went unto physicians. And Asa slept with his fathers, and died in the one
and fortieth year of his reign.") The name, Hebrews' Disease, obviously
indicates that the disease occurs in Jews and hence must have a
genetically determined background. And if the fathers have eaten sour
grapes, what's the use of taking care of the children's teeth? More than
fifty years ago a brilliant New York surgeon wrote a paper on its etiology
(a good word, meaning causation; you'll hear it used again, so don't
forget it) in which he pointed out the curious fact, discovered by
himself, that only Russian Jews (he was a German Jew) were afflicted by
the disease. A gifted writer and an iconoclast, he said the cause must be
found in geography, not in genetics. "In a narrow band from the Baltic to
the Balkans" lies the origin of the disease, he said. He investigated many
cases of the disease in New York City; he found it only in immigrant
Russian Jews, except for one man of Irish descent born right in the city.
The Medicine Af
Being a persistent cuss, he finally drew from the man*s mother the
admission that the father may have been an itinerant Jewish peddler.
Before he could proceed with further research into the dietary and sexual
habits of his series of patients, someone else discovered that another
ethnic group could have the same disease and the next edition of a
surgical textbook alliteratively described its incidence in Jews and
Japanese. By this time other researchers got suspicious and when Finns.
Frenchmen, Norwegians and native New Englandersall uncircumcised-were
discovered with Hebrews'
Disease, the name was changed to thrombo-angitis ob
literans, descriptive of its appearance under the microscope, and its
etiology was more carefully looked into. (But not yet discovered. Some
doctors have given up in disgust and say the disease doesn't even exist.
Others have attributed it to causes as varied as fungus infections of the
feet and the eating of ergot-infested rye bread. On the basis of the
latter, a textbook of therapeutics advised that sufferers from the disease
could drink all forms of alcohol except rye whiskey.)
On occasion doctors put names to what isn't there. Some diseases, like the
emperor's new clothes, just don't exist. Remember how superfluous
characters in Victorian novels were removed by brain fever? That was not
encephalitis. Brain fever was a literary disease. It came soon after
prolonged study, extreme worry or overwhelming emotion, as when a girl was
jilted. it usually ran a short, fatal course-two or three paragraphs.
Other characters died of a decline; that was good for a chapter or two.
Brain fever is no longer prevalent, nor is teething fever, but idiopathic
colic, chronic cystic mastitis, and visceroptosis are still
around.
(Idiopathic is a great word for doctors. It means the disease started by
itself. That means that the disease needed no cause, no creator; it just
sprang up. There's idiopathic thrombocytoper.ic purpura, idiopathic
scoliosis, idiopathic atrophy of the skin, and lots more. Idiopathic is
the medical version of the Big Bang theory in astronomy. Who needs God,
allergies, bacteria, viruses or chromosomal aberrations in such diseases?)
I'm not nit-picking. Naming has perils. Dr. Frank Cole, editor of the
Nebraska State Medical Journal, describes cardiac arrest. "It means that
the heart has stopped, and whose heart does not stop when he dies? It
suggests that the heart stopped without a cause, and
' You don't believe that? See a book called Poetry Therapy, edited
by Dr. J. J. L-dy, published by Lippincott, 1970.
The Name of the Rose
this is pure nonsense. The idea that people die during anesthesia from
mysterious causes is as old as anesthesia.... But while the false idea
will not die, the name is changed every twenty years, so that the theory
appears fresh and new and therefore modern and valid. And we have called
this non-existent disease by such names as status lymphaticus, status
thymolymphaticus, status periculosus, primary syncope, cardiac standstill,
asystole, and now cardiac arrest. These are lovely names, they are
sesquipedalian. Their elegance and their very length almost convince us.
But people die on the operating table because they are not watched or
because they bleed. Mysterious agents do not ... kill patients 'between
two heart beats.' Death in surgery is due to respiratory obstruction,
cardiovascular accident, hypotension, and to other members of a list, all
of which are known and have proper names."
Naming, you see, is different from diagnosis. It can be as hazardous as
calling on the devil, pacts with Satan being notorious for being weighted
in his favor. Plato, in The Republic, said, "Of a surety, they give
strange and newfangled names to diseases." Perhaps you ought to be as wary
of the glib doctor as that old Greek implies he was. When a doctor
pronounces that the disorder he is treating is thus-and-so in Latin, ask
him what it is in English and don't be satisfied unless he can make you
understand. Refuse to be mystified. It is better for you to know that he
doesn't know. Then vou won't take the medication (which may have potential
for harm) be orders, and you can always go to another doctor. You'll save
money and possibly your health.
Naming can be harmful to your health. When a doctor orders a regimen of
drugs or diet on the basis of a named but undiagnosed condition, you are
the one who's taking a chance, not he. My niece was recently treated for
what the doctor called Winter Vomiti-ig Disease. (That sounds like the
opposite of Summer Diarrhea, which has disappeared in name and in fact. It
was shown to be caused by bacteria, not solstices or equinoxes, and
disappeared after the introduction of pasteurized milk.) Whatever Winter
Vomiting Disease was, it was not helped by a starvation diet and opium in
the form of paregoric.
2.
Naming is also a short-cut for the doctor-to tell his
13
colleagues something unfit for untutored ears to hear. I don't refer to
fellatio, which has already appeared on the drama pages of the New York
Times. I mean the private language of the profession. Every predatory
trade has its argot, vividly expressive of its contempt for its victims.
The secret language of doctors is used only in intimate discussions in the
privacy of hospital staff rooms or the golf course. There, where there is
no need for magic, the practitioners thereof talk about patients and their
illnesses with their hair down. A very short glossary follows:
Acute Lunipuk-acceiited on the second syllable-aii acute illness of no
importance, not Nvorth the I)other of having an accurate diagnosis, selfliniited, responding well to reassurance and any prescription xvhether
taken or not.
Chronic ,Iloldavian Crit(I-itp obscure skiii disorder that the doctor can
treat for at ]~ast three times before sending the sufferer therefrom to
another doctor, and (la capo.
Cinque Test-a useless laboratoi~~,, test done at the patient's insisence
and accomplished by pouring the specimen down the draiii.
Crock-an uncooperative patient NN,Iio stubbornly persists in I)aviiig the
sanie complaints time and again despite the expert ministrations of his
plin,siciaii.
Disease Entity-an actual disorder from which a patient stiffers,
recognized by the doctor as uiidiagiioseid but which he will nevertheless
treat until a diagnosis is established.
Fecalemia of the Circle of IVillis-the circle of Willis
being the arterial supply of the brain, this condition indicates that the
patient's head is full of feces.
Gork-a vegetable; i.e., a patient whose mental faculties are clouded to
the point of total apathy.
Neuremia-a form a hypochondria, the implication being that the patient's
blood hurts.
Sliopper-a patient whose dissatisfaction with diagnosis
or treatment is expressed by his going to ar.otlier (not necessarily more
skilled) doctor.
More definitions could be given, but this is not, after all, a dictionary.
The. Medicine M
IV
The Sacred Precincts
"Examine me, 0 Lord, and test me; try out mv reins and my heart."
-Psalms, 26:2
-\Ia~,be you're not sick enough to have the doctor see you at home. You go
to his office.
Civilized people need no skulls hanging outside the cave, no totems, no
jujus to awe them and fill them with appropriate respect when they enter
the doctor's office. You're beyond that. You don't expect alembics,
skeletons, or fetuses in bottles, as your fathers did. In keeping with
your sophistication and your recognition that the practice of medicine is
a business-although unlike other businesses-you look for a crisp,
efficient place where your ills can be attended to quickly and you can be
on your way.
That expectation is part of the modern ritual of the healing art. You have
been indoctrinated by magazine articles, by television interviews and by
club lectures. You know that a doctor who is so behind the times that he
has no appointment system must be a scientific laggard. You're aware that
the doctor has many demands on his time (like golf or bridge) and you
don't want to waste it. You3re in Ms office to do your business and get it
over with.
The waiting room is shiny clean, with uncomfortable chairs and a magazine
rack filled with the latest issues of Fortune, Vogue, Golf, Travel,
Outdoor Sports, Playboy, and National Review. The chairs are uncomfortable
because tradition can't be broken with entirely. Hard chairs keep you
painfully alert. The magazines are those the doctor has read and
discarded; they give you an idea of the kind of man he is. On the walls
are hung reproductions of Picassos, Braques and Mir'os for the wealthy
suburban crowd; there are also bland autumn landscapes and "The Stag at
Bay" for the runof-the-mill bunch. At the far end of the room, sometimes
behind a glass partition, is the receptionist dressed like a priestess in
a see-through white uniform and a permanent smile, She is the dragon who
guards the filing cabinets, the telephone, the intercommunication system,
the billing ledgers and the appointment book. She has another function-to
politely and firmly ward off presumptuous visitors to the doctor. You have
an appointment, so you're welcome.
if this is your first visit, you give the receptionist such vital
statistics as she may ask for, including your Blue Shield and Social
Security numbers. If your doctor is really with it, you'll receive from
her a history sheet which you'll be asked to fill out. You understand that
the selfhistory is a great timesaver for the doctor. At a glance he'll be
able to see what your medical background is and what you're complaining of
now. You want to be accurate (after all, it's your health), so you
carefully fill in what Papa and N,Iama died of and what Aunt Nliiinie had
and you check whether you had measles, nialai-i.t or tsutstigqmuslii
fever. (That last one's a litinidiiiger, isn't it? Some other good ones
ar( verrug,t perti\-iana, ainhum, Q fever, Rocky NIountaiii spotted fever
and kala-azar.) Then comes the list of present symptoms starting with
backache, belching and blurred N,isioii. Half the time you're not sure
whether the term fits your case. For example, "sensation of fullness after
meals." Does that mean that you have -. good appetite and get pleasantly
replete or that you have such a bad appetite that a little food fills you
up quickl~,? You don't want to appear ignorant, so you leave that space
unchecked. The selfhistory sheet is fascinating. It's a better timeconsumer than a crossword puzzle or a coloring I)ook. You suddenly realize
that your appointn-tent was for two-thirty and it's now past threefifteeit. You mtistn't keep the doctor waiting. You hurriedly rush tlirou,,b the
remaining questions
1
Z7~
and turn the paper in to the receptionist. That makes you feel as though
you're back in grammar schoolrather a pleasant feeling, to shake off all
those years. Then you settle back and wait for your summons.
Now you have time to see who else is waiting. Your confidence in the
doctor rises. It's a good thing, you congratulate yourself, that you chose
him. Look at the patients: well-dressed, clean, obviously upper upper
class. Even later on, after you've become a regular visitor to the doctor
and you've discovered that the stylish lady is actually the wife of the
storekeeper down the
The Sacred Precincts
street and the distinguished-looking man is an electrician, N-our
confidence is not diminished but rather heightened. You're impressed by
the doctor's demoer-atic spirit and his love for humanity. He's willing to
treat anyone, of any race, color or creed, providing he will pay. Or his
insurance company will. Or Medicare.
At last your name is called. You enter the sanctum
s;anctorum, the consulting room. Here you find a thick carpet, two or
three comfortable chairs (but you sit on the straight-backed one by the
desk) and a general sense of luxury. On the walls are displayed framed
diplomas and various certificates. The desk, very imposing, has on it a
large picture of the doctor's family, an ornate Florentine inkstand, eight
or ten medical journals, in-add-out correspondence boxes piled high with
letters and insurance forms.
The doctor leans back in his swivel chair and, peering over the Ossa and
Pelion on his desk, asks, "What's %,our chief complaint?" See, no
nonsense. He gets right to the point. The selfhistory yo,-i've so
painfully struggled over lies open on the desk before him, but he ignores
it. You tell him why you came. He makes a few notes and while you're in
the middle of describing the terrible heartburn you get after eating your
mother-inlaw's stuffed cabbage, he gets up and ushers you into a small
cubicle where you undress and put on an examining gown. You're supposed to
know whether it goes on frontwards like a kimono or backwards to expose
your behind. That skimpy costume, the stock in trade of medical humorists,
is not comic. It is a real put-down.
Nakedness puts you in a properly humble frame of mind. It is also used for
a similar psychological reason in concentration camps, prisons and draft
board examinations. Unclothed, as Erving Goffman points out in Asylum, you
are immediately inferior to the civilized man who stands before you. You
become painfully conscious of the roll of fat, of the pimples on your legs
and of your ridiculous lack of muscle or curve.
The doctor then proceeds to the examination, even though he's already made
up his mind about what ~-ou've got and what he's going to do about it.
Medical schools teach that 80~'c of diagnoses can be made on the history
alone. But without an examination you wouldn't believe him no matter bow
graphically you've detailed the spells of vertigo, deafnese and buzzing in
your ears you've come about. (That's known as M6nie're's syndrome. Don't
get hypochondriacal.) You're inspected with and without instruments in
various orifices, palpated, percussed, and auscultated (to auscultate-to
15
listen to, medically).
Inspection is comprehensible. If the doctor doesn't look, he can't see.
Although sometimes you may wonder, because of his abstracted expression,
whether he does see. I can assure you he doesmost of the time. A medical
joke (a favorite with doctors) tells of the proctologist who fails to
remember the faces of his patients but who never forgets a posterior.
Palpation is also understandable, particularly when the doctor's hands are
cold, making you wince when he places them on your abdomen. (I use abdomen
because it is correct. Stomach is not; it is an internal organ of
digestion. Belly is okay, but to the layman-no offense meai-it-it carries
connotations of infantilism and vulgarity, if not downright obscenity. The
layman is wrong, but this is not the place to correct either his
anatomical confusion or his niceiiellyisms; let him read The Song of
Solomon or Venus and Adonis.) Palpation is a form of laying on of bands, a
highly regarded tliaumaturgic practice. Many doctors neglect palpation
when it does not seem necessary to them for diagnosis. The abandonment of
that method is one of the causes of public discontent with the profession.
"He didn't even put a finger on me!" The patient, particularly the
neurotic searcher after magic, feels he has been shortchanged if the
doctor hasn't touched him. He becomes a devotee of chiropractic, which
means literally the laying on of hands.
Percussion, the tapping of the chest, sometimes of the abdomen, rarely of
the skull, is a technique by which the doctor presumably gathers
information about the contents of the cavity he is percussing. From
variations in tonal quality he can deduce what's wrong or what's missing
despite the loud piped-in music overhead. The variations are slight; the
doctor must have a keen ear. Fortunately, most doctors have that; it is
constantly being trained by hi-fi stereo recordings of jazz concerts and
Tchaikovsky symphonies.
At last comes auscultation, the most arcane and yet the most routine part
of the examination. The stethoscope is the badge of the profession. It is
an insigne that belongs exclusively to medical men. When you see a garage
mechanic using a stethoscope, you get suspicious that he's reaching above
his station and for your pocketbook. When a nurse takes your blood
pressure and uses the stethoscope, you're skeptical. She doesn't seem to
have the same careless finesse with which the doctor brandishes the
instrument. The stethoscope protrudes from the doctor's pocket or lies
atop all the other tools in his bag. (Dr. Watson carried his in his bat,
as
you recall. It must have reeked of pomade.) The mysteriotis instrument is
applied to your chest and moved from spot to spot, while the doctor has a
faraway look in his eyes as though he were listening to the music of the
spheres. He tells you to breathe in and out, to stop breathing
(temporarily, of course) and to say ninetynine, and all the time he
listens as though to distant harmonies. There's no question that he's
finding out something about you. Alas! That's not true. I must ad~,aiice
your knowledge by dispelling that illusion. A recent survey of physicians'
stethoscopes showed that about 20% didn't transmit sounds bilaterally and
that more than half distorted the sounds. Blood pressure determinations
which depend on the use of the stetboscope, it follows, are often
fallacious, as Dr. Irvine Page pointed out in an editorial in Modern
Medicine. He ended his statement there with, "Far better no measurement at
all than an inaccurate one. I mean it!"
But auscultation cannot be omitted, as palpation often is. It is an
essential part of the ritual. For you have gone through a ritual. The
doctor sincerely believes be is doing something to aid him in diagnosing
your ailment. He may rush through the procedure, be may rely on defective
instruments, be may not know the rationale for what be is doidg, but be
would never, never, never skip the examination, no more than he would
expect to examine N,oti gratis. lie needs the ritual as much as you do.
Aiid most often he does discover what's wrong with you.
(Sometimes he discovers what isn't, too. Two true stories: A doctor
discovered a lttiiip in the (yroiii, suspected malignancy and adx-ised a
biopsy, he i,,iiored all the infected pimples on the patient's le,, which
had caused secondary enlargement of the lynipli iiodes of the groin.
Another doctor of my acquaiiitaiice found unexplainable very low blood
pressures in his patients until be realized that his sphygmomanometer
[blood pressure machine] was poorly calibrated.)
The examination being over, you I re ready for the next phase: the
necessary laboratory tests (discussed in another chapter).
And then you're back in the consulting room. Like a prisorier awaiting
verdict and sentence you wait for the fateful words. You don't have long
to wait. The doctor tells you what you have and what must be done to
restore you to health. No sweat-for him. He has the diagnosis at his
fingertips. He's not a lawyer who tells you he'll have to look up the law
before be can solve your problem. He's not a minister who must seek divine
guidance. He knows. His knowledge is encyclopedic. It
The Medicine M
ranges through the alphabet from Addison's disease to zoster. And be gives
you the benefit of his knowledge, almost with a snap of his fingers (This
is known in the trade as a snap diagnosis). You leave the office relieved
and happy you chose such a -,ood and smart doctor.
I quote now, deadpan, a statement by a Georgia doc
tor from a book entitled Liste-i to Leaders in Medicine,
a book for the guidance of fledgling doctors: "A suc
cessftil doctor is one who inspires confidence ... with
out any ti-ace of dishonesty, he can appear competent to manage the
patient's problems, even though he admits that he cannot give an exact
diagnosis or treatment at that moment. Most patients are confused and
frightened; they need the reassurance and comfort that a trained person
can give them." A trained person, indeed! Trained in what? Science or
magic? Reassurance and comfort are what a mother gives when she kisses her
child's scraped knee. If that's what you want, okay, but then don't blame
the doctors when more than that is not forthcoming. To have good doctors
there must be good patients, and good patients are not those who seek
father figtires and mother substitutes when they need fungicides or
mercuhydrin. SympatliN~ is no surro ate 9
for science.
No wonder the author of Ecclesiasticus said (38:15),
"He that sinneth before his ),,Iaker, let him fall into the bands of
physicians."
Unfortunately, sin is common. So is sickness. Sometimes you must go to a
doctor. But when you go, go as you Would to a technical adviser, not as to
a ballowed sacerdote. Don't be bemused by the opulence or severity of your
surroundings. Keep your wits about you. NVatch Nvhat the doctor is doing.
Observe him. You can tell whether his examination is a series of
mechanical motions, whether be is attentive to your description of your
ailment, and whether his diagnosis is meaningful. A good doctor needs no
bedside manner. A good doctor establishes rapport with his patient by his
sincere interest in helping the patient get well, not by his skill in the
ritual of the examination.
And there is another objective test of a doctor. Do his patients return to
him? Do they recommend him? Patients may like to be mystified and fooled
but not all of the time. They quickly separate the wheat from the chaff.
When they recommend a doctor, it's because they've had good results with
him-or because they like his hand of magic. You may too. That won't last
long if you're an intelligent consumer.
History and Physical
"The cause is hidden, but the result is well known." -Ovid, Metamorphoses
Sometimes the doctor has to struggle to earn his money. A true story:
"Sit down, Mr. Robinson . . . Yes, right there . . . Now, what do you
complain about?"
"It's my back."
"How long has it been bothering you?"
"A long time." (There's a definite answer for you.)
"Oh, sure, but that's from when I broke my leg in 1946 and infection set
in and I had to have the bone scraped." (Something new has been added-he
didn't count that as an operation or a serious illness.) "Does it
interfere with your sleep?" "No."
"Does it hurt when you cough or sneeze?" (I'm still
"How long, would you say? A month, a few days, six on the disk deal.)
%%,eeks?" (Polite, but insistent.)
"Oh, it isn't steady. It comes and goes." (Getting nowhere fast. Might as
well give up the chief complaint approach and try the personal history.)
"What kind of work do you do?"
"I'm not working now."
"Well, what kind of work did you do?"
"All kinds, sort of general, you know." (I don't, but the question wasn't
too important anyway.)
"Have you had any serious illnesses or operations?"
"_just tonsils, when I was a kid."
"Now, when did you first have trouble with your back?"
"Well, it started off slow-like and then it got worse, so I used some
stuff my mother-in-law said was good, and it went away. But then it came
back, so I went to the drug store and Mr. Schneider there, he gave me
something to put on, but that burned too much so I just used compresses,
and then it went away again, but then it came back one day after I was
bowling and I think I must have caught a cold or something there-they have
this bench right against the outside wall, and it's always cold from
opening and closing-and then it went away by itself, and then. . . ."
(He's talking at last, but so far be hasn't said anything. Time to put a
stop to this.)
"Does it hurt when you bend?"
"No."
"Do you have any pain down your leg?" (Sorting through the causes of
intermittent backache in my mind, I consider a protrusion of the
intervertebral disk.)
"And how! But only sometimes, when I have the pain, that is." (I'm making
no progress at all. Better give this up and try the direct method.)
"Point to where the pain is."
"Oh, I don't have any pain now." (Touche'! I used the wrong tense.)
"When you do have the pain, exactly where is it?"
11 Right here in the back of me." (Waving a band in the general direction
of his posterior from the neck to the end of his spine.)
"All right. Go into the next room and strip." (I give up. I know when I'm
licked.)
I note scattered black and blue marks on his thighs. "Did you fall
recently?"
"Uh, no, Doc. Those marks are from where I take the needles-you know, for
my diabetes." (He didn't count that as an illness, either. )
"How do you regulate your dosage?"
"I go by the urine test and whether I feel itchy. My wife says maybe I
scratched myself and that's how I hurt my back originally." (I get the
mental picture of the poor man reaching around to scratch at an
inaccessible place and getting a backache. No sense talking any more. I go
through the whole routine: checking blood pressure; listening to heart and
lungs; looking at the throat, eyes, ears, nose; palpating the abdomen;
testing the reflexes verything but a rectal examination-before I get to
his back, which I go over thoroughly.)
"No limitation of motion, no muscle spasm, no sign of any spinal trouble,"
I tell him.
The Oracles
"It is surprising that an augur can see an augur without smiling."
We smile at those bygone days when the medicine man was aided in his
diagnosis of disease by inspecting an astrologic chart or by noting in
which way the smoke from a burnt sacrifice drifted. We have laboratories,
bright automated chambers with chromium-plated machiiiery, flashing lights
and row on row of test tubes, flasks, slides and other glass
paraphernalia. We also have portable machines whose tentacles attach to
variotis parts of the body and which spew out rolls of graph paper
imprinted with wiggly waves. We have dark rooms, too, in which tubes
looking like an illustration from a science-fiction magazine are
manipulated from distant control consoles. Biochemistry and biophysics are
enlisted in the aid of the doctor seeking to find out what's ailing us or
bow we are responding to treatment. Reliance on laboratory findings is
taken for granted as a sign of a physician's acumen.
Not with dread but with abiding faitb you submit to having your finger
pricked or blood drawn for examination. Not with doubt but with confidence
you accept the results of the tests. To do otherwise would relegate you to
the ranks of the backward and the benighted. You are a true believer in
Science and what could be more scientific than a laboratory? Oliver
Wendell Holmes, a physician as well as a litterateur, cautioned that
"science is a first-rate piece of furniture for a man's tipper-chamber, if
he has common sense on the ground floor."
Too many people believe that Science is a religion. Theologians have
sarcastically given that new creed the name of scietit~sin. Scieiitism has
more followers, especially amongst the presumably better educated classes,
than Christianity or Zen Buddhism. Those followers mistake the map for the
road, the X-ray photograph for a likeness, and numbers for facts.
Their belief sometimes leads to hilarious requests by patients who pride
themselves on being cautious consumers of medical sergices. They are not
going to be taken in by withcraft. Oli no! They are skeptics. They demand
proof in black and white. "How do you know, Doe, unless you Xray my
nerves?" and "Where's the proof of your diagnosis?" Their skepticism
lasts, how
-Cicero, De Natura Deorum
ever, only until a ghostly photograph is exhibited until a sheet of paper
typed with numbers from 0.2 5,150,000 is shown to them, When those are
display they sit back and relax. Th4at's proof.
Because most doctors are really good guys at he and are sincerely trying
to make their patients better well as themselves rich, they have submitted
to an often encouraged the naive belief in the infallibility o laboratory
objectivity. They have become victims of their own propaganda despite the
repeated cautions of medical hierarchs. One of the latter says that
doctors are lazy: they won't take time to make a diagnosis; they find it
easier to write slips for laboratory studies than to think. Another
decries both the practitioner's failure to use his senses in trying to
make a diagnosis and his reliance on the laboratory. Dr. Walter Alvarez
puts some of the onus on the patient: "Often I cannot blame my brother
physicians for sending a patient for useless tests because every so often
I have to do it. If I didn't he or she would think I did not know my
business, or I was highly negligent.... What I often marvel at is that so
many people, and even well educated ones, have no interest in what an old
clinician of enormous experience thinks about their problem: they want
tests."
All right. So you have tests. Even if it turns out that not one of them
shows up anything of importance, there was always the possibility that
they might have. Why take chances? You're only spending money and who
stints on money where health is concerned? Man, are you wrong! The odds
against you are almost as bad as those on double aces at a Las Vegas crap
table, and sometimes worse.
Suppose you rend the sacred veil and enter into the mystic chambers of the
laboratory. And suppose you ask what's going on, but don't ask the
acolytes in white but instead ask the very high priests, the teachers and
mentors. Ask them to tell you in all honesty what bappens when the
machines stop whirring and the centrifuge stops rotating. They won't tell
you. You're the patient. I will, but only in their own words.
Let's start with an electroencephalogram. Everybody who's seen Ben Casey
and Dr. Zorba argue about one
The Oracles
kno,.%-s what that is. That's real up-to-date! And so im
pressi%-e! Think of it-electrodes stuck with gooey jelly
here and there on the scalp, a ilick of the button, and little waves
appear on paper. You just take it for granted that an electroencephalogram
is a necessity for accurate diagnosis of a brain lesion. Alackaday! The
EEG (not to be confused with the ECG, which is discussed further on) is a
weak reed on which to rely. I quote, without comment, from an article
written for practicing physicians by Dr. Charles M. Poser, bead of the
Division of Neurology at the University of Missouri School of Medicine in
Kansas City: "Fifteen to 20clc of patients with clinically establisbe~
convulsive disorders never have an abnormal EEG. On the other hand, 15 to
20clc of the general population with no history of convulsive disorders
have an abnormal EEG. . . . Rarely can it [the EEG] give clues to the
etiology, or more important, to indication for long term management ... it
is seldom imperative for diagnostic purposes.... In summary, the value of
the EEG must be considered comparable to that of all other laboratory
tests. It does not make the diagnosis. . . ."'
Well, maybe the electroencephalograms are too new. Maybe all the bugs
haven't been worked out of the procedure as yet. What about X-rays? Nobody
can lie about a picture. Statistics can lie but not a picture. Something's
there or it isn't. There's an abnormal spot in the lung or there isn't;
there's a blocked area in the intestines or there isn't. The truth is
otherwise. The evidence for such a sharp dichotomy is woefully lacking. In
1948 Dr. L. Henry Garland, in his presidential address to the Radiological
Society of North America, reported on results of a survey of readings of
cbest films. (The readings were supposedly not of the same nature as the
readings given by gypsy fortune tellers.) The survey showed that as many
as 24c/c of radiologists differed with each other in their interpretations
of the same films, even in the cases of extensive disease; worse -the same
radiologists disagreed with themselves to the extent of 31'/c on the same
films when read at another time. In 1955 it was found that 32.2~'(, of
chest Xrays that showed definite lesions in the lungs were misdiagnosed as
negative.' In 1959, eleven years after the first survey, with only experts
doing the readings, 30~/c, disagreed with another's reading and 20~Ic,
disagreed with their own readings at another time. And now ' eleven years
still later, a study at Harvard, reported in the American journal of
Epidemiology (91:2), showed that radiologists disagreed with each other on
the diagnosis 201/c of the time and with themselves 10cl(, of the
time on a second reading of the same film. Not much progress, is there?
All right, you say, so mistakes are made, but on the whole who can deny
that mass X-ray screening of chests is of no value? just think of all the
cancers that are picked up that the possessors knew nothing about! Your
reasoning may be logical, but it doesn't conform with the facts. In a mass
screening program covering more than 7,900,000 persons there was "no
appreciable gain in salvageable lung cancer patients. Symptoms appear to
be the best clue to the presence of bronchogenic cancer. "5
Don't go away-here's more about chest X-rays in the early detection of
lung cancer, with an orbiter dictum: "It would seem prudent, therefore, to
use clinical sense to a high degree and to continue the search for a test
other than routine X-ray examination for presymptomatic diagnosis of
cancer, not only of the lung but of other sites as well. "6
That last remark gives you pause, doesn't it? The doctor implies that Xrays of areas other than the chest are equally fallible. He's right but
I'll give you only two more examples. You've been discouraged and
disillusioned enough already. One survey showed that 10~'(-, of cancers of
the large intestine were overlooked as well as 27c/,, of cancers of the
cecum, the blind pouch at the junction of the small intestine with the
large.' In 1965 another survey of gastrointestinal Xrays showed that in
300 consecutive cases readers disagreed in their diagnoses 30c/c, of the
time."
Why go on? That Halloween photograph of your insides serves to bemuse you
(and too often your doctor) into thinking that it's tangible and visible
proof that a diagnosis has been made. Sort of reminds you of the laurel
leaves on which prophecies were written so ambiguously at Delphi, doesn't
it?
Laurel leaves were safer. X-ray radiation is intrinsically hazardous. At a
conference on tuberculosis, two Nova Scotia investigators reported that
the repeated chest fluoroscopies done on female patients in the
3 American Family Physician, April, 1968, p. 75. There will be many
references like this from now on, If I didn't give them, you might think I
was making up the dreadful information to come.
4 Dr. J. Yerushalmy, American Journal of Surgery, January 1955.
-5 Dr. H. Wilson, in the Medical Journal of Australia, 2:936, 1968.
6 Dr. P. Lesley Bidstrup, British Journal of Radiology, May, 1964, p. 357.
Drs. R. Cooley et al., American Journal of Roentgenology, Ra
dium Therapy, and Nuclear Medicine, August 1960, p. 316.
1 Dr. Marcus J. Smith, in the same journal, July 1965, p. 689.
20.
The Medicine.V4
course of their treatment could probably be implicated in the unusually
high incidence of breast cancer that later developed. Nine times greater
in the fluoroscoped patients than in a control groi-ip! In an interview
with a reporter from Medical R'orld News (September 11, 191'0), Dr. Robert
D. Moseley, Jr., chairman of four national committees on radiation
hazards, said about mass screening for gastrointestinal disease, the use
of Xrays for diagnosis in large populations, "The dose [of radiation]
received is higher and the incidence of disease turned up is lower. in
these cases I'd have serious doubts about using radiologic procedures in
routine screens." A British survey showed that even one X-ray during
pregnancy can significantly increase the risk of a child developing cancer
in the first ten years of his life. "This radiation risk is greatest
during the first trimestei-, but it exists throughout pregnancy."' Dr.
Donald R. Chadwick, of the United States Public Health Service, says,
"Responsible authorities agree that all radiation exposure carries some
risk of adverse biologic effects, and therefore iiiinecessarv exl:)ostire
should be reduced or eliminated whenever p~ssible." Note the cautious
attittide expressed in the last clause. If it's unnecessary, why reduce
it? Why not eliminate it altogether? Can it be that X-rays are necessary
for mystification?
Let's leave Dr. Casey and Dr. Roentgen and go on to sweet Dr. Kildare and
Raymond Massey (or Lionel Barrymore, depending on bow old you are). The
interiiists at Blair General Hospital put much stress on the
electrocardiogram. You've seen them holding that strip of paper in their
hands and shaking their heads. You've even seen the cardiac monitor's
electronic eye go across your TV screen with the i-ip and down waves that
trail off into a horizontal line with the patient's exittis. That can't be
magic; that's science and accuracy. Want to bet?
In 1956 a survey similar to that done with X-ray interpretation was done
on electrocardiographic tracings. The reports of the ECG readers varied by
20~'c, between individuals and 20~~ on rereading of the same tracing by
the same individual at a later date." Eight years later, in 1964, an
editorial in the Journal of the American Medical Association entitled,
"The ECG: a Re-appraisal" commented that variations in the
electrocardiogram were so great, depending on the time of day, activity,
digestive function and so on, that interpretation must be undertaken with
great precaution because so many normal people showed changes usually
regarded as evidence of cardiac pathology. The editorial concluded with a
plea for standardization of
ECG testing to preclude error. What was done? nothing. Electrocardiograms
are still being taken before and after meals, during the stress of an
acute illness, after arguments with nurses and orderlies. In 1968 Dr.
Irving Wright, a prominent clinician, wrote, "A relativel%common error is
the over-interpretation of minor eleetrocardiograpliic chances ... the
physician should not jump to hasty conclusions. . . ."" Interpretation is
not always at fault. "Electrocardiographic technique is often poor and
sometimes execrable," writes Dr. Abraham Genesin, Associate Professor of
Medicine at Johns
12
Hopkins University School of Medicine. He lists eleven common causes of
bad tracings (reversal of limb leads, twisting and torsion of the cables,
etc.). He warns that the ECG cannot substitute for the data derived from a
full history and physical examination. Even the speed at which the paper
rolls out makes a difference, a Boston cardiologist says, because abnormal
values for the PR, QRS and QT intervals ma%appear (Those radio-messagelike capitals indicate various portions of the wave shown on the
electrocardiograph).
A persoiial experience: While I was a patient in an intensive care unit in
a hospital, the nurse reported that the monitor showed an abnormally fast
heart rate. An electrician came, fiddled with some wires and switches on
the ECG machine, and proudly said, "There! I've got his rate down now."
Right thei-i I almost bad a heart attack. Why? Because I could have been
electrocuted. Dr. Carl W. Walter, Chairman of the Safe Environment
Committee, Peter Bent Brigliem Hospital, in Boston, says, "No one knows
how many patients die of undiagnosed accidental electrocution in hospitals
each year. An insuraiice actuary . . . estimates the number at 1200, but I
am inclined to believe that the true figure could be . . . something like
5000. These unrecognized electrocutions are usually diagnosed as cardiac
arrest, and they occur during resuscitation efforts or during the
application of electric moiiitors, pacemakers, or other appliances. . . ."
He goes on to discuss the causes of the 110-volt macroshock that everyone
is familiar with, and then, ". . . there is also the problem of
microsbock. When we
9 Drs. A. Stewart and G. W. Kneale, in Lancet, 1:1185, June 6 1970.
Dr. G. L. Davies, British Heart journal, 1956, vol. 18, p. 568. Internist
Obseruer, April, 1968.
12 "Abuse of the Electrocardiogram," Current Medical Digest,
July, 1968.
The Oracles
bypass the electrici'ty-resistant skin and insert cardiac catheters,
sensors, and probes, premature systole or ventricular fibrillation [not
good, believe me!] can be caused by a current almost too small to measureas low as 10 milliamperes. Voltage gradients as low as 5 mv may be
significant. Leakage currents may occur in a path from the patient's
tissues to the ground even when the electric device is not turned on.
Transient voltage when a switch is flicked can also stimuiate the heart.""
The ECG is a tracing that purports to give information about the state of
the heart muscle. The latest si-irvey showed that only in one-fourtli of
the cases of proved acute myocardial infarction (proved by autopsy or
subsequent course) was the ECG positive; in half, the findings were
equivocal; in the remaining fourth, they were totally neqrative, what the
doctors called false negatives. That's not all. In more than half of
another series without infarction, the ECG was grossly abnormal, false
positive. As a totally reliable diagnostic
14
tool, the ECG is woefully lacking.
A New Jersey cardiologist tells of a patient who, at the age of 46, had a
"routine" electrocardiogram which showed that he had inverted T waves in
leads 1, 11 and the left V. So instead of going to North Carolina on a
golfing vacation, he disgustedly went to the hospital for four weeks with
a diagnosis of coronary artery disease. T waves remained inverted on
discharge and were still inverted two years later when a large hiatus
hernia .N-as found. Twenty years later, the T waves were still tinchanged
and the patient was playing eighteen holes of golf without any symptoms.
The moral: an inverted T does not always a coronary make."
So much for reliance on the mystic machine. Its value for diagnosis and
for checking the result of treatment is limited, and yet it is used almost
routinely. Not because of the venality of the doctor, but because
sometimes he is taken in by his own propaganda and more often because of
the childlike belief of his patients in gadgetry.
And sometimes the doctor is stupid. Or careless. Which is the same thing
'when it comes to reliance on clinical laboratories. In the first place,
too often the doctor doesn't know beans about the quality of the
laboratory doing his tests. In eighteen states and the District of
Columbia anybody-that's right, anybody-can open up a laboratory and
without control or supervision advertise for and get customers. Secondly,
the doctor is just as impressed as is his patient by an array of
equipment. He seldom asks who uses those fancy machines-a qualified
technician or one hastily trained for
a stopgap job?
Good training is necessary. Those laboratory manipulations look simple,
especially if you remember a little high school chemistry or biology. But
don't forget, it is not the starch content of potatoes that is being
measLired. And the more sophisticated the instruments, the better trained
must be the personnel using them.
From time iiiimemorial medicine men have concerned themselves with the
excretions from the body as diagnostic criteria. The Hindus discovered the
presence of diabetes iiiellitiis by tasting the urine to determine whether
it was sweet. Centuries later, Western doctors made diagnoses bv pouring
the tirine into a flask and holding it up to tiie light. This quaint
practice, called uroscopy, can be seen pictured in Renaissance paintings.
(Inversion of the flask, emptying the urine on the floor, was depicted in
old woodcuts as a sign that the patient would die. It was the medical eqiiivalent of thumbs down.) A modern doctor takes that specimen of urine and
hands it over to a technician. The specinien is either freshly passed or
brought to the doctor in a variety of containers, \,arN7ing from a -,allon
jug still redolent of laundry bleach to a tiny perfume vial. I lian,e
often seen both. I can understand the former but the latter gets me. Had I
been a real scientist I would lian-e asked the patient how she git that
dram of urine into that wee, wee (no pun intenZIed) bottle with the
pinpoint opening. (I never did ask, but I'm still interested and think
about it on long plane rides.)
The technician exaniiiies the urine in mintite detail and submits a report
on it. On that report (if be looks at it ' ) the doctor ma~, base his
diagnosis. I say "if he looks at it." One study showed that ward nurses
didn't bother doing even the simplest tests on urine because they knew the
doctor didn't pay any attention to what was written on the chart. But
suppose he does look at it? Is it helpftil? I have known doctors who point
to the report of albumin and other abnormalities in the urine and on that
basis confidently make a diagnosis of kidney disease. Are they right?
Alas, not so. I quote: "In
l-'3 Greatly, abbreviated froiii an article in Hospital Practice,
Dec(,iiiber, 19,-0, p. 53. 'I'lie whole article is well wc)rtli reading,
as well ,is "Is l'otir CCU [Cardiac Care Unit] Electrically Safe?" by Dr.
Hans A. %'on dc-r Nlosel, in Iledical-Siirgical Review for Octol)er, 1970,
p. 28, in which the "tri,,7ial" iiiieroshock that catises death is vividly
Ciescribecl.
14 Dr. D. Short, Briti-~h Medical Journal, 4:673, Dec. 14, 1968.
1-5 Dr. Bernard B. Eichler, Journal of the Medical Society of New
Jersey, 66:582, October, 1969.
22
view of the unfortunate tendency of many physicians to rely on the
laboratory report for a diagnosis of nephritis, the fact will bear
emphasis that here, as in most conditions, the laboratory observations
present only a part of the data necessary for a diagnosis."" The painter
John Opie, when asked with what he mixed his pigments to get such glowing
colors, replied, "With brains, Madam, with brains." The doctor must do
more than merely go through the ritual of testing the specimen. He must
mix the report with brains.
Here are some fascinating statistics on blood examinations. In 1936 red
blood cell counts on the same blood showed a gross variation of between
16~'c and
17
28~Ic error when done by different technicians. In
1969, except where an electronic cell counter was used, the error was
still at least 16~(-, which doesn't permit the distinction between
microcytic and macrocytic anemia, often the only purpose in doing the
count.
Doctors aren't always happy with the results of their augtiries. They make
periodic surveys of their techniques. I don't know why. After they're
done, nobody seems to pay much attention to them. if you think red cell
counts were bad-look at blood chemistries.
A survey showed that in hemoglobin determinations 22~'(- were grossly
wrong and of those, 677c were beyond the reasonable bounds of error. Blood
glucose tests were so far out of the way that 377c were worthless for
diagnosis. Total blood protein determinations677c wrong."
Some enterprising biochemical engineers have tried to do away with the
human errors inherent in measuring, diluting and testing the blood. They
have made ingenious machines working on the computer principle, machines
that take a sample of blood and run it through a series of operations,
ending up with figures that prestinial)ly could not be more accurate. But
a machine slightly off I)alaiice may make the same rriistake repeatedly.
And with an automated analyzer doing eleven tests at oiice, let us say,
there will be eleven more chances for error. Too bad the engineers have
not reii-teii-ibered the litimaii being who uses the figures. I quote
again: "The woi-.dei-ftil accuracy of laboratory data done Nvitli modern
apparatus may increase the credulity of those who employ them. A dial or
scale accurate to the third significant figure triples the credulity of
the Liser. He forgets that multiplying the complexity of the insti-timent
multiplies the opportunity for Purely mechanical error.""
Especially in mass screenings the computer laboratory may be
niisleadiiig. Iii a group of healthy subjects
having fifteen tests done, aboi-it half of that gr would show one or more
abnormal values due purely el-iance. NN'itl-i fifty tests, nine out of ten
would sbon%' least one false positive test. Arid that's with good
chinery with a tolerance limit of 95~'r accuracy per t
N~'liv? Plain mathematics. In one test the probabili that a healthy
iiidividtial will have an abnormal test is (.95), or 5""r. For two
independent tests, it is 1-(.95 .95), or almost 10~~(. For 15 tests, it is
1-(.95) 15
over 50"( chance of error. Dr. Bruce Schoenberg of t National Cancer
Institute says there is not much phN. cians can do al-)otit these results
except live with the Or-iise their heads when they find a result that
doesn jil)e with other findings. Unfortunately, many docto have so little
confidence in their diagnostic skills th they believe the machine rather
than what they see
bear.
Even in the absence of error, too much data makes forest out of trees. In
medicine this has been calle dia 'gnostic overkill. If a very large amount
of information is offered, say the communications engineers, the general
effect is that which they call noise. To make the information meaningful,
irrelevancies must be filtered
out or the relevancies exaggerated.
And finally, too often human frailty bits the most accurate laboratory
work when the figures are transcribed onto the hospital chart or the
office form. The laboratory reports a blood urea nitrogen of 10.2; the
floor clerk oii-tits the decimal and it appears as 102. Mrs. Mary Smitli
in Room 203 has a white blood cell count of 23,000; '~irs. NI. (for
Madeline) Smith in 207 has a couiit of 7000; 1 have seeii the counts
transposed. The urine analysis on Nir. Jones shows sugar but the plus mark
is put alongside the albumin box.
That's all technique. You can't put all the blame for
error on the doctors. What about interpretation? That's
strictly his job. A true (and sad) story: Some busybody in a hospital
suspected that the doctors weren't looking at the laboratory reports. He
checked on his suspicions by covering the figures with masking tape, thus
forcing the doctors to do a minimum of physical work if they really wanted
to see those figures. About a third didn't bother to peel off the tape!
Worse yet, of those that did, another quarter paid no attention to grossly
abnormal
16 Todd and Sanford, Clinical Diagnosis by Laboratory Methods,
Tentb Edition, p. 177.
17 Drs. \Iagath et al., Aniericati Journal of Clinical Pathology,
1936, vol. 6, p. 568.
11 Drs. W. P. Belk and F. W. Sunderman, same journal. November, 1947, vol.
17, p. 853.
'~' Dr. XN'. B. Bean, Archives of Internal Medicine, 105:188, 1960.
The Oracles
results! They looked without seeing or they saw without perceiving.
The laboratory tests need interpretation as much as X-ray pictures do. An
o\~erzealous doctor worries when the hematocrit drops from 41 to 39 or the
blood cliolesterol rises ten points. He forgets the errors inherent in
technique. A difference of ten per cent in blood counts, for example, is
insignificant, as is the change from 180 to 190 in a blood glucose
determination. And when the norm lies between 150 and 200, as in total
blood cholesterol, what difference does it make if one report says 175 and
another 190?
Another mistake in interpretation arises from scientism: if the test is
positive, that's proof. Not so. An example: Increased serum enzyme
acti\,ity has been regarded as diagnostic of acute coronary thrombosis.
But a 1968 report to the College of American Patbologists pointed out that
false positives were common in various gall-bladder disorders, so much so
that clinical judgment was more valuable tl-ian the enzyme test in the
differential diagnosis of the two conditions.
Why go on? A long list of laboratory reports may look good on the
patient's chart, but how much does it contribute to his getting better?
Now let's go back. There's no denying that the X-ray tube, the ECG machine
and the blood analyzer are necessary in some cases for the doctor to
establish a diagnosis or to follow the results of his treatment. But the
doctor must be aware of the perversity of inanimate objects and not rely
on machinery alone. He needs to use his senses and his brains as well. He
must be able to interpret tests properly, to discard grossly deviant
findings and to take to heart the mistranslated but true Hippocratic
dictum that experiment is fallacious. (The original said experience.)
Dialectics: it's up to the patient to ask why the repeated tests, why the
daily electrocardiograms, why the weekly chest X-rays. To ask why-and not
be put off (or down) by double IL-alk.
More dialectics: it's also up to the patient not to ask for irrelevai-it
tests because they're fashionable (for example, monthly Pap smears). The
doctor will undoubtedly oblige the patient by having the test done. Cui
bono?
Still more dialectics: NVben a doctor tells you a test shows that you have
a condition you could not possibly have, tell him be's wrong. Insist that
he repeat the test in another laboratory or do a more thorough medical
examination. Two examples: The X-ray series shows gallstones in the gall
bladder, but your gall bladder was removed years ago (I bad such a case!).
The
Wassermanii 'Lest for syphilis is positive, but you are a
very moral person and never even use public toilets; maybe you have
mtiiiips or infections mononucleosis, both of whicii sometimes give the
same positive reaction as syphilis.
By now you realize that doctors are almost as credulotis as their patients
when it comes to laboratory tests. Right there is a danger to liealtb-and
sanity. NVben the medicine iiiaii I)elieN,es that his din,iiiatioiis mean
something, that's worse for the patient than when he cynically ptits on an
act for the sake of impressing the suff erer.
I give you no\N, ~iii example of !-low far credulity can
go. Suppose you had no si,,-iis or symptoms of diabetes
melitis, I)tit you li~i% e ~i N-er\- careful doctor- on the alert for
latent disease. Ui-i~~ic analysis shows no sugar. The doctor checks ~,otir
fastiii,, blood sugar and your blood stigar two hours aftei- a iiieal.
They're normal. Then be does a glucose tolerance test and then what is
kiio-,N,ii as a provocati\-e cortisone ,Iticose tolerance test. They're
normal, too. YoLi tliiiil.N-oti'i-e off the liook? Not at all. The doctor,
a specialist in his field, says sadly, "Too bad. You have pieclial)(,tes." And if you tl-~ink that's a made-up stoi-N-, I i-efer N-oti
to a pai)iplilet 1)~, Dr. Ai-tbtir Krosiiick under the iiiipi-iiiiattir of
the New Jersey State Department of Health. Ttiei-e the clia-,nosis of
prediabetes is said to be confirmed by negative laboratory and clinical
findings. There is also a treatment prescribed for this condition. The
treatment consists of blood tests ever-,- six months for the dduration of
the patient's life.
NN'heii the m~,.,,iciaii I)elie\-es in his ina,,ic, beware!
The Medicine
Vil
A Commercial Note
"Rielies and honor are what men desire; but if they attain to them by
improper means, they should not con
tiiiue to hold them."
-Confucius, Sayings
Clinical laboratories have progressed from the homemaiiufactory stage to
modern atitomated assembly line techniques. As in industry in general,
each new machiiie represents an outlay of capital that must be recotiped,
but it also leads to a lessening of the man-hours needed for finished
products. Furtbermo.-e, the number of highly trained (and hence expensive)
operatives is reduced; the new techniques can be taught quickly to the
equivalent of semiskilled workmen. A conventional twelve-test blood
chemistry profile thus may cost less than five dollars-aiid even less in
large laboratories. Automation, therefore, can give more and more services
at lower and lower costs to the consumer, in this case, the patient.
It can but does it? Dr. Herbert Lansky, past president of the New York
State Society of Pathologists, has said that doctors contracting with
large laboratories have not passed on the. low cost to their patients. Dr.
E. G. Shelley, reporting for the American Medical Association judicial
Council, describes one bill sent to a patient: "Serolog~,, $7.50;
cholesterol, $7.50; ,Ilkaliiie phosphatase, $'1.50; complete blood count,
$12; sedimentation rate, $6; glucose, $5; urea, $7.50; uric acid, $7.50."
All these tests were done for a charge of $6 to the physician. For an
outlay of $6 the doctor got $60.50. Not a bad markup, huh?
The College of American Pathologists denied in February, 1969 that it
tried to cut down competition and keep prices high, but it agreed,
nevertheless, to a cojisent decree rather than fight an antitrust suit.
Senator Philip Hart, in February, 1970, chairman of a Senate Antitrust and
Monopoly subcommittee, reported that his staff found that a quarter of a
billion dollars could be saved annually by reducing the fees paid to
hospital pathologists for unneeded but mandatory token supervision.
(Nlandator~,-by state laws and the joint Committee on Accreditation of
Hospitals. NVlio would dare accuse such honest men as our legislators and
our top doctors of having no sense? It's more charitable to say they are
in collusion.) A common method of paying hospital pathologists is by a
percentage of the gross laboratory charges, 9.57c of which are for routine
work which the pathologist did not order, perform, interpret or record.
The pathologists say that a laboratory test
without interpretation is worthless. They are right, but one wonders
whether the cost of that interpretation is not set at what the traffic
will bear. (Besides, they don't interpret the tests. The attending
physician does-if and when he does.)
It is now possible for doctors to enter into contracts
with commercial laboratories for a flat fee ranging from
$75 to $300 a month. Such a contract entitles the docto to an unlimited
number of tests for any number of patients. Naturally he passes on the
cost of the service to his patients, just as he passes on the cost of
bandages or hypodermic needles. Unfortunately, two temptations arise, one
mindless and one mercenary. Because the cost is so little the doctor may
order tests indiscriminately, with the expected consequences: the level of
informational noise is raised; the doctor is lulled into a sense of
complacency that be is giving good medical care; and the patient is
deluded into thinking that laboratory tests are essential for diagnosis
and treatment. The second temptation is yielded to too often. The doctor,
by charging his patients "for laboratory tests," can make a very good
profit on a service which was originally intended as a help to him. Such
overcharging exists, enough to bring about complaints to medical
societies, threats by insurers to refuse payments, and warnings of
governmental action.
The judicial Council of the American Medical Association has clearly
stated its position: let the patient pay the laboratory for his tests; let
the doctor be the interpreter of those tests. Thus the suspicion of
markups or commissions will be avoided and the doctor will not be tempted
to be a profiteer. The statement sidesteps the issue. It looks backward to
the time when tests were "handmade" for each patient and doesn't take
cognizance of the new contractual laboratory arrangemeilts.
Considering that the public spends three billion dollars each year for
laboratory work, the question of fees is not trivial. Who is to benefit
from the advance in technology-the patient by lower costs or the doctor by
increased income?
Vill
Members of One Body
"The art of medicine in Egypt is thus exercised: one physician is confined
to the study and management of one disease; there are of course a great
number who practice this art; some attend to the disorders of the eyes,
others to those of the head, some take care of the teeth, others are
conversant with all diseases of the bowels; whilst many attend to the cure
of maladies which are less conspicuous."
-Herodotus, Euterpe
Holy Church is indivisible and one, yet it varies in its observances and
rituals. The same with medicine. just as theology's aim is the salvation
of souls, so medicine's avowed goals are the prolongation of life and the
alleviation of stiffering. And medicine, too, has Byzantine rites and
special services for special occasions.
Unfortunately no councils, conferences or synods exist in medicine for the
guidance of the patient. The honest citizen is left on his own, standing
before the directory in the Medical Arts building while be decides on
which thaumaturgist he should call on to relieve his headache. Should he
see an ophthalmologist, an otolaryngologist, a neurologist, a psychiatrist
or (if he's old-fashioned and believes all troubles start in the bowels) a
gastroenterologist? Often he pays his money and makes his choice and if
he's lucky he makes the right one.
What's a specialist? All physicians are licensed by the states of their
residence and are presumably equally competent. The license is acquired
after a course of study, a period of apprenticeship and the passing of an
examination. A specialist is a doctor who has been further tested by selfconstituted superiors in a sharply delimited area of practice. If he
survives the ordeal, he is admitted to a College or to a Board or to a
Society, and he can charge higher fees for his services. It then follows
by circular reasoning that if he charges more money, he is better
qualified, money being the criterion of worth in society, and if he is
better qualified, he deserves more money. The specialist chooses his field
not for the love of science nor for the sake of mental
exertion, but because the hours of labor are sborter and the work is
easier. This was said as long ago as 1876 by Dr. John Shaw Billings in the
American Journal of Medical Sciences. The training and initiatory ordeals
have become more rigorous since that time, but the postulants' reasons for
undergoing them remain the same.
The work doesn't always look easier. Sympathy is readily aroused by the
sweat streaming down the tribal dancer's body as be circles around the
patient or by the complicated maneuvers he makes with the sacred gourds.
The newspapers record and television shows how the specialist manipulates
with dexterity the awesome, shining instruments of his trade. And everyone
knows of the tremendous advances that have been made in the medical
specialties. Only a carping critic, a sotir-puss reactionary, would dare
to denigrate those Diplomates and Fellows.
Or an innocent child who can't see the emperor's new clothes. Or a tribal
malcontent who's seen the wizard's all-too-buman nakedness under his
feathered robes.
2.
"Anyone who goes to a psychiatrist ought to have his head examined."
-Samuel Goldwyn
Let's start with an easy specialty, one that's been the target of
innumerable jokes. But remember Freud's dis
covery-that the mocker of sacred subjects is showing his fear (and
respect) in a distorted fashion. Wits have been shooting barbs into the
psychiatrist's couch for so long that the stuffing's coming out. We'll
leave wits (but not our wits) aside and look with an unprejudiced eye at
the ministers to the mind diseased, the savants whose specialty is
omniscience. These hierophants are unique among specialists in that they
freely discuss their methods in lay publications, and in spite of that
they remain invested with the aura of magic. Why not? Mental aberrations
are the closest thing we moderns have to the possession of the ancients or
the stolen souls of aborigines. One who undertakes to treat such
aberrations is almost automatically looked on as a mystic, as one who has
a key to the secrets of the unknown.
The psychiatrist enjoys being thought so: though be modestly disclaims any
knowledge unavailable to the educated man and points to the wide
distribution of psychiatric articles in the popular press, be hesitates
not to give opinions on the sanity of Presidential candidates, advice to
educators, and analyses of the motives of revolters against this best of
all possible worlds. Some psychiatrists make no bones about being
magicians. On April 24, 1968, Professor Morton L. Kurland, a psychiatrist,
gave an address at the Academy of Medicine of New Jersey on "Oneiromancy-A
Brief Freudian Study of Dream Interpretation." And on March 22, 1971, at
the annual meeting of the American Orthopsychiatric Association a paper
was presented entitled "What Western Psychotherapists Can Learn from Witch
boctors," in which the point was made that witch doctors use the same
methods and techniques as do Western psychotherapists-and with about the
same results!
Psychiatrists have a standard formula for prognosis, the foretelling of
the course of a psychic disorder. They say, "This is a complex situation.
Time and extensive [and often expensive] treatment will be necessary."
They are not being mercenary. The very rich may be treated differently
from the very poor, but time and expense remain the same, maybe even more
time for the patient and more expense for the taxpayer in the case of
those confined to public asylums. (An excellent study, Social Class and
Mental Illness, by Drs. Hollingshead and Redlich, points this up quite
well.)
But it would be supererogatory to confine criticism for the present state
of affairs in the treatment of mental illness to the poor (not in the
economic sense) psychiatrists, already the butt of night club comedians,
ignoramuses and those members of the intelligentsia in
The Medicine Mei
search of novelty. The last, because of their vocality, help to set the
public image of the psychiatrist. They have decided opinions about
psychotherapy, a branch of the medical art, more so than they would dare
to have about another branch, such as neurosurgery. Their opinions lean
now in one direction and now in another, depending on what the book
reviews have to say about the latest "discovery" in the field of mental
illness.
The fact remains that psychiatrists are in great demand, an indication
either that as a nation we are getting nuttier or that Parkinson's Law has
found another application. In New Haven, Connecticut, for instance, in
1940 there were only three psychiatrists; in 1958 there were 24 full-time
psychiatrists, 33 part-timers, and 32 residents in training who took care
of patients in clinics, Veterans' Administration hospitals and a private
psychiatric hospital. During those eighteen years New Haven's population
rose by only 5000. In Iowa, part of the supposedly stable Midwest, where
the population increased only from 2,621,736 in 1950 to 2,757,537 in 1960,
the number of psychiatrists rose from 15 to 95. In ten years the
membership of the American Psychiatric Association more than doubled from
its 5534 in 1950 and reached 16,000 in 1967.
The increasing supply is the result of the increasing demand. Why? Do the
psychiatrists get such good results with their therapies? Are asylums
being emptied? Are the couch springs regaining their resilience? Let's
see.
Take psychoanalysis, for instance, in any of its orthodox, schismatic or
heretic forms, a branch of psychiatry many believe to be fundamental to
the treatment of the sick psyche. (Psyche comes from the Greek, meaning
soul or butterfly. Both develop in grubby darkness and both aspire to the
heavens.) Very few careful evaluations of the results of psychoanalysis
are available. That's not because of negligence or because the analysts
are afraid of what the surveys will show. It's because evaluation is so
difficult. Is the patient better because he no longer worries about
wetting his bed (You've heard that joke before?). Is she better because
she no longer argues with a stupid superior at work or an equally stupid
husband at home? Is the insomnia or the palpitation or the weepiness gone?
The problem of evaluation is one of goals, and too often the goals are as
nebulous for the doctor as the patient. Nevertheless, some studies have
been made. Dr. Frederick Wertham, a Voice of Authority, a former president
of the American Association for the Advancement of Psychotherapy, says
that 60~'c of psychoanalyses are more harmful than
Members of One Body
helpful and that four out of five analyses are not indicated in treatment.
The most extensive study of the results of psychoanalysis showed that
fewer than half of the analyzed patients were cured." More recently, the
American Psychoanalytic Association, who might be supposed to be
prejudiced in favor of their own specialty, undertook a survey to test the
efficacy of psycboanalysis. The results observed were so disappointing
that they were withheld from publication .2 ' There is a little semantic
problem here. Cure may not be the correct word (unless used in the
religious sense of a ctire of souls) for a therapy aimed at relieving the
anxieties and the discontents caused by upbringing and civilization.
But only one-twentieth of psychiatrists are analysts. Do the other
nineteen-twentieths do better? Not so you could notice it, especially in
the major psychoses. Fortyseven per cent of the hospital beds in the
United States are still occupied by the insane, a percentage that has not
varied from 1950. The number of patients confined as "schizophrenic" has
risen .22 Enthusiasm for lobotomies gave way, when the cold statistics
were in, to excitement over insulin shock therapy and electric shock
therapy, and that in turn subsided in the face of sober examination of
their results. Insulin shock therapy is still used in a few hospitals
(despite the occasional accompanying fatalities, euphemistically called
irreversible comas) on the ground that schizophrenia is such a hard
condition to treat that anything that ever gave the slightest chance of
improvement should be continued. Undismayed by their previous failures,
the psychiatrists turned to the marvels of psychotropic drugs, and as the
latter multiplied, their beneficial restilts became less noticeable. An
old adage in medicine states that the more remedies there are for a
disorder, the less likely any one of them will be of value. That seems to
be true in the psychotherapies.
Not that the psychotherapies are worthless. Not at all. The degree of
their worth is what's arguable. A recent book (Hunwn Behavior, by Berelson
and Steiner) states that sober and scientific evaluation of psychotherapy
shows it to be no more useful than general medical advice or counseling
for neurotics, but still useful. A group of psychiatrists reported that in
a followup study of psychiatric outpatients, very many were "better" after
five years, and of those traceable after ten years most were better; the
type of psychotherapy seemed to make no difference." In another critical
review of the results of psychotherapy, it was pointed out that fast
improvement was the chief virtue
of psychotherapy; without it, improvement took place,
but very SloWly.21
Some psychiatrists have a ready explanation for everything. If the patient
is late for his appointment, he's resisting treatment; if he's early, he's
overanxious; if lie's right on time, be's compulsive. Because of it's
pretension to a sound comprehension of human motivation, the field of
psychiatry is very broad. It even has to do with school problems like
underachievement ("if he's so smart, why doesn't he get all A's?"),
overachievement ("he's too clever for his own good"), aggressiveness
("he's a bully"), submissiveness ("she's always too ready to do what she's
told"), showing off and withdrawal, nail-biting and pencil chewing, et
cetera, et cetera.15
But why do people seek out the psychiatrists? Why are they in such great
demand? Because, faced with problems requiring fundamental changes in our
society, men find it easier to categorize those problems as "basically
psycbogenic" than to do the harder work of determining the causes of
juvenile delinquency, drug addiction, the rising divorce rate, industrial
absenteeism and racial strife. In a secular world where God is either dead
or has given us tip in disgust, men turn to the gods at hand. They run to
those they believe know everything about the workings of the human mind.
They cry out like children for Papa to forgive their trespasses, to brush
their troubles away, to ease their guilt and excuse their mental laziness
by tittering a few charms like Oedipus complex, identity crisis,
ambivalence and flight from reality.
Their demands are unreasonable. The chasm betweeii what people think
psychiatrists do and what their limited techniques can do is great indeed.
But it wouldn't do for a healer of souls to tell them that. People expect
so much of the psychiatrist that some doctors forget their mortal
limitations and succumb to a
20 Dr. R. P. Knight, "Evaluation of the Results of Psychoanalytic
Therapy," American Journal of Psychiatry, 1941, 98:434-446.
21 Dr. Anthony Storr, "The Concept of Cure," in Psychoanalysis
Observed, Baltimore, 1968, p. 57.
22 Dr. Felix von Mendelssohn, This is Psychiatry, New York, 1964, p. 207.
23 Drs. A. il. Stone et al., "Intensive Five Year Follow-up Study of
Treated Psychiatric Outpatients," Journal of Nervous and 2VIental
Diseases, 133:410, 1961.
24 Dr. Hans J. Eysenck, "Effects of Psychotherapy," International
Journal of Psychiatry, 1:99, 1965.
25 Dr. S. S. Radin, "Mental Health Problems in School Children,"
Journal of School Health, 32:392, December, 1962.
belief that they are deities. They arrogate to themselves the role of
expert on everything from colonialism to cancer prophylaxis. For the
former read Dr. Frantz Fanon's book, The Wretched of the Earth. The latter
was discussed at a conference at the New York Academy of Sciences (May
1968), where three prominent psychiatrists suggested that, on the basis of
their findings that cancer patients they studied were people who denied or
suppressed emotion after experiencing personal loss or tragedy, cancer
might one day be prevented by propbylactic psychotherapy. A reading of
their reports is illuminating: they illustrate what is called the logical
fallacy of the undistributed middle.
Psychiatrists are not quacks or charlatans. They sincerely believe that
what they do has value in the treatment of mental illness. The problem
with the practice of psychiatry lies in that very belief, Too many
psychiatrists exaggerate their own capacities. Dr. David Cooper, a
psychiatrist himself, says of his colleagues, "in fact, many psychiatrists
are second-rate doctorspeople who could not 'make it' in general medicine,
but this fact does not limit the possibilities of pretence.... The doctor
is invested, and sometimes invests himself, with magical powers of
understanding and curing. Whether the formal training of psychiatrists
includes qualification in magical omnipotence is perhaps uncertain, but
the image is reinforced and perpetuated in many ways ."2' The selfaggrandizement of many psychiatrists often leads people to seek more and
more of their opinions and advice, thus encouraging those psychiatrists to
assume still greater divine attributes.
Such psychiatrists have good precedent for their arrogance. Freud wrote a
monograph on Leonardo da Vinci based entirely on a bad translation of his
writings. He wrote another, Moses and Monotheism, that displayed his
imperfect acquaintance with Egyptology and comparative religion. (I won't
even mention Totem and Taboo, that masterpiece of Schund-Anthropologie.)
There is a dialectic relationship in the ballyhoo about psychiatry and its
overrating. Both the witch doctor and his patient are at fault.
But no one denies the existence of psychic disorders that make the
sufferer therefrom miserable, that distress his family, that may be a
danger to the community. We can't dispense with psychiatrists. But we can
divest them of their priestly clothes and remove them from the pedestals
we have erected for them. We can recognize that they are human beings
using experimental tools to deal with illnesses of uncertain etiology.
The Medicine Me~
We can demand from them a clear statement of their goals when they start
to treat a patient. We can insist that their results be visible to others.
We can ask for interim reports on progress or the lack of it. One thing we
cannot afford to do and that is to be brainwashed by torrents of mystical
phrases so that we forget what the purpose of psychiatry is-the treatment
of a sick man or woman.
3.
A CYNICAL FABLE
Once upon a time there was a young man whose family wanted him to be a
physician. The young man, who was a dutiful son and anxious to avoid the
draft, therefore entered a premedical course at a university.
After five years, be received a Bachelor of Science degree; be bad taken a
year off for cultural study in Europe. The young man then entered medical
school. Because of the shortage of physicians and the faculty's resultant
need to pass everyone, be did not find the course of study terribly
onerous. In due time, five years later, the young man was graduated with
the degree of M.D. The extra year, to widen his horizons, be bad spent
with various peace missions in those benighted foreign countries just
emerging into the dawn of NVestern civilization and its concomitant
diseases. The year further broadened his knowledge of non-American
cultures. He learned that being poor is worse than being rich, that
English is more widely understood than Xhosa, and that flush toilets are
not a necessity.
The young man then entered upon an internship that was to prepare him for
the exigencies of actual medical practice. He learned that emergeiicy-room
service means the treatment of the common cold, that illegible handwriting
prevents calliiigs-down for errors in charts and that laboratory tests
save wear and tear on brains.
On the completion of his internship, the young man, being very patriotic
and having no other recourse, undertook his military duties. Because he
was highly trained and was an officer, he spent two years at a military
post, at which be okayed treatment given by the master sergeant of his
detachment, gave lectures on the dangers of venereal (as opposed to
martial) combat,
26 Dr. David Cooper, Psychiatry and Anti-Psychiatry, London, 1967, pp. 24,
93.
Members of One Body
and learned the extraordinary serviceability of the third person, passive
voice and subjunctive mood in writing reports. He was then ready for a
residency. Not fODd of blood and bored by physical examinations, the young
man decided to become a psychiatrist, psychiatry also being a branch of
medicine that requires no great otitlaN7 for equipment. He took up a
residency in an ultramodern psychiatric hospital complete with computers
for fudging statistics, a pharmacy full of psveliotropic drugs of unknown
menace, and beatitiftilln- decorated opeii wards with the most cleverly
disg,,iised restraints. The hospital had a steady inflow of the
meii4LaIIN, ,N,eak and halt. It also had an equally steady outflow of the
same, in order to maintain its reputation as an up-to-date institution
with neither back wards nor simple custodial care, a place that
specialized in active tlierap~,. The young man was taught that cold baths,
colectomies, lobotomies and shock treatments were antiquated and harmful.
He was so well indoctrinated with psn~cliopharmacological propaganda that,
on the completion of his residency, be was unprepared for the Dews that
iii order to be a successful psychiatrist lie needed a tliorougb analysis
of his own psyche. Having during this time married and, therefore, being
in need of money, the man (young now oiiIN, 1),, ~courtesy) entered
practice while he underwent aiia]N,sis. Of course, aware of his
limitations, be treated oiil-,, psychotics and neurotics. He spent most of
his free time giving lectures (unbolstered by such trivia as facts) to lay
groups on the great advances made in the field of psychiatry. These
lectures, be was told by his older and presumably wiser colleagues, were
ethical means of
publicizing his name and qualifications and thus of increasing his
practice. His advisers were correct. The man was soon able to provide his
family with the necessaries of daily living commensurate with his status:
a large house, several cars, private schools for his cliildren, expensive
jewelry for his wife, and a couiitr~--eltil-) membership for himself.
Meanwhile, the man went on NN7itll his analysis. Faced with the range from
ortliodox to radical-from the phylacteries of the Freudians to the nudity
of the neo-existentialists-tlie Diaii (an educated consumer) made the
"best buy," an analysis of ii-ioderate length and of little cost. The
analysis resulted, first, in his developing insights
into his character, and, second, in iiiakiii,, strong den
A rnerica?i
attitude toward medical doctors as uiewed in
fenses against the defects he uncovered. He learned (MORE), the rnagazitie
of iotirnalism.
humility by finding lie was not so sinart as be thought
29
be was; be coped with that by boasting, in papers read before medical
associations, of his therapeutic successes. He learned that his Yoals were
as limited as his capabilities-, lie stii-ii-iotiiited that kiioNN,Ied,,e
by raising his fees, to prove his ~,N,ortli and the value of his
aiiil)itioiis. He recognized his egocentricity; lie overcame it by mockmo(lest disclaimers of credit for his increased activities in
coiiiiiiiiiiitn, affairs.
Because of his professional attainments and his civic activities, I)N7 the
time the iiiaii had reached the end of middle age, lie was freqtieiitIN,
called on to give his opinion on subjects which affected the lives of his
fellow citizens: the iiieiital capacities of Presidential iioiiiiiiees,
the pi-oplix,laxis of teeii-age drug use, and the relative values of Nar~,iiig educational theories. Ile became kiio\\,ii as an expert, appeaiiiit, before Coiigi~essioiial committees, testifn,iii(r in court cases and
being a TN' panelist.
At the dinner gi\,eii him on the tweiity-fiftli aiiiii\-ei-sary of his
starting practice, the man responded to the toasts I)v a statesmanlike
speech critical of the risiii(r generation, \vlio were (lepartiiig from
the basic \,irtlies of iiite(ti-itv, honest\, and self -discipline, who
forsook peaceful i-efoi-iii for riot in the cause of revolution, and who
refused to benefit from the paiiiftill-,, acquired (tliroti(rli
experience) wisdom of their elders.
NIORAL: There's always a market for skiiii milk iiiasqtteradiii(r as
cre~iiii.
30
The Medicine M
4.
"A fashionable surgeon, like a pelican, can be recogiiized bv the size of
his bill."
J. C. Da Costa, The Trials and Triumphs of a Surgeon
At first glance no specialty would seem to be more removed from the
pseudo-religiosity of psychiatry than surgery. Surgeons are not concerned
with what was and when; they deal with here and now. The objects of their
attentions are not such stuff as dreams are made of, but concrete matters
like stones and tumors. They treat their patients not by exorcism but by
the laying on of hands. (Surgeon is derived from chirurgeon, from the
Greek cheir = band and ergon = work.)
And yet what more resembles an esoteric religious ritual than an
operation? It's done behind closed doors, with the anxious relatives
waiting in an anteroom until the surgeon, still wearing his robes of
office, comes out and shakes his head sadly or beams wisely before he
says, "Well, we've done what we could. Now everything depends on his
recuperative powers." That's an overt admission, if I ever heard one, that
the mystical forces of nature will do the rest, the surgeon having
complied with the placatory rituals. It is also a variant of covering-up
(q.u. sup.)
(Incidentally, have you ever noticed how doctors of all description dote
on the regal we? "We'll do some tests," and "We'll decide today." It's as
though standing by his side is an invisible man almost as competent as lie
is.)
What actually goes on behind the closed doors is not entirely a mystery;
you've seen the spectacle dozens of times in the movies or on TV. Clad in
white pajamas, masked, bead covered, the surgeon solemnly scrubs and
scrubs and scrubs his hands. (You've never seen the I)Lllge in the sock
underneath one of the legs of those pajamas. 'I'bat's where the surgeon
stows away his billfold. And in the movies the plot advances during the
scrubbing. In real life the time is spent conversing about golf, politics,
the student revolt and so forth.) The surgeon walks, arms up, elbows
dripping, into the operating room and is assisted into a covering garment
and helped with the putting on of rubber gloves. Then he takes his place
at the operating table under an inverted bowl of lights. The patient lies
there unconscious, tubes attached to his outstretched arms, a balloon on
his face; he is covered with drapes and surrounded by the surgeon's
assistants, nurses and onlookers. The rest you don't see. You only hear
the slap of
hemostats, the sharp requests for gauze, scalpel, scissors, the
whisperings of the attendants wheeling in strange and cumbersome
apparatus. Occasionally the surgeon, without removing his arm plunged into
the patient's innards, turns his head to have a nurse mop his sweating
brow. The scene is dramatic, yet calm, like the part where Charlton Heston
strikes the rock.
And afterwards, when the surgeon describes what he's done, the drama
remains. As in Greek tragedies, the very language is elevated in keeping
with the solemnity of the occasion. The abdomen is incised, not cut; the
tissues are divtilsed, not spread apart; the wound is sutured, not sewed.
Oliver Wendell Holmes (still not the jurist) once dryly remarked, "Some
men ligate bleeding vessels; others tie them. Hemorrhage stops in either
case."
The awe and respect with which surgeons are held
can be judged by the size of their fees and by their
pomposity. They are so surrounded by apprehensive
patients, reverent families and subservient nurses that
they brook criticism neither by laymen nor by their peers (if they admit
they have the latter). It took man years of nagging, baggling, and
politely applied force majeure before surgeons permitted tissue committees
in their hospitals. The sole purpose of such committees was to establish
the justification for surgery; they set up standards and applied sanctions
against those men doing unnecessary or bad surgery. They proved their
value. In one hospital 262 appendectomies for acute appendicitis were
performed in 1953; in 1954, when a tissue committee was organized, only
178 were done, but the pathologist reported that 36~',, of the appendices
removed were not inflamed; by 1957, only 62 11 acute" appendices were
operated on, and the percentage of normal appendices removed in those
cases dropped to 16 ~~. 2,- In another hospital, 593 appeiidectomies were
done in 1952; after the organization of a tissue committee in 1956, only
184 appendectomies were performed. Operations for the separation of
abdominal adhesions declined in the same period from 133 to 60;
cliolecystectomies (removal of gall bladders) dropped from 173 to 117, but
more thorough operations (exploration of the common biliary duct) rose
from 16
21
to 38 in those cases.
27 Dr. Harvey R. Sharpe, Jr., "The Effect of a Tissue Committee
on Appendectomy in a General Hospital," Wisconsin Iledical Journal,
59:135, 1960.
21' Reported from the Nlissotiri Baptist Hospital (St. Louis) in the
Bulletin of the American College of Surgeons, 43:449, 1958.
Members of One Body
I don't want to imply that surgeons as a class are unethical or
incompetent. They are not, and far less so than many of their colleagues
in other specialties. They may be unthinking, they may be carried away by
their very competence into doing operations they shouldn't be doing, and
some of them may even be stupid, but why should the public expect more of
them than of officials chosen by the electorate?
Let's return to the operating room and see what you I ve missed at the
first showing. Remember that rigidly aseptic atmosphere where gei-iiis are
scrubbed and washed away? The patient has been wheeled into the operating
room on a trol]eN,-cart and lifted onto the operating table. Stop and
think. NN'bere has that cart been? Its wheels lian-e traversed hospital
corridors where the shoes of N,isitors lian,e brought in dirt, where
doctors attending infected cases have trod, and now it comes into that
nice clean operating room. And look at the patient. EN,eryone else is
capped and masked. If the patient wears a cap or turban, it has been
displaced by his journey from his room to the operating suite or it will
soon be displaced by the anesthetist. The patient doesn't wear a mask; be
can be talking nervously and spraying millions of bacteria from his mouth
until be is put to sleep (temporarily, of course, since that etipbemisrn
does not apply to htimans). Nine times out of ten he is wearing leggings,
draw-stringed bags covering both legs to the midcalves. lvby? If be's so
dirty, why not clean him up first in his room, and if be's not, why does
be wear the leggings? I called several hospitals to ask why the leggings
were worn. The operating room supervisors unanimously answered, "It's
traditional." How much more is traditional?
Many things. Start with the scrubbing. A recent study by Dr. Ralph C.
Richards, professor of surgery at the University of Utah Medical Center,
showed that prolonged scrubbing was unnecessary, that 70~Ir ethyl alcohol
removed more bacteria from the bands in one mint-ite than were removed in
ten minutes of scrubbing with soap. Prolonged scrubbing is a carry-over
from the days when surgeons first stopped operating in frock coats.
The drapes, too, are traditioiial-tbose drapes under which the patient's
temperature steadily rises. Multiple layers of sterile cloth drapes were
devised to keep the entire operative field free of external contamination
and to insure that blood and pus would be quickly absorbed by the fibers
of the drapes. But now there are lightweight plastic coverings that can be
taped around the field and disposable light sterile paper drapes for the
rest of the corpus (not corpse). Use of both obviates washing and
sterilizing linens, and saves time ii-i the operating room.
Asepsis, the prevention of bacterial infection, is the reason for the
scrubbing, the rubber gloves, the drapes, the sterilized instruments. Some
hospitals have operating suites, access to which is by special elevators;
all require that the surgeon cover his street shoes with cloth boots or
wear shoes reserved for the operating room. Such regulations are
comprehensible until you consider: what about the orderlies and nurses who
bring the patients to be operated on? Are their shoes permanently shielded
from infectious bacteria outside the operating room? I would think that if
breaks in aseptic technique must be so zealously guarded against, then all
personnel working in the operating rooms should be subject to the same
rules.
Furthermore, anyone who has ever been in the emergency room of a busy
hospital has seen how such a place functions. Wounds are sewed, with
sterile instruments and suttires, of course, but all around is a hubbub:
police officers wander in and out; relatives weep, wail, and blow their
noses; nurses come from taking the temperature of a child with a sore
tbroat into the room where a laceration is being repaired; masks and caps
are conspicuously absent. And yet torn skin beals and no infection supe.venes. Well, you sa~,, rigid asepsis is impossible under emergency
conditions. A nagging tbought-maybe it is also IlDiiecessary under others?
Oi-ie medical center has broken with tradition by doing what it calls a
mini-prep (in presu-mably already infected cases-a sort of what-the-liejl
attitude) : the area is washed well with soap and water, and only three
towels are used as drapes. "In the year tl)at we have been using this
approach we have been impressed
21
[with it] ...
What aboi-it war surgery done, as you've seen on the screen, under teiits, in the open air, ;.n a manner at which any self-respecting operating
room supervisor would bold up her bands in bar.-or? The statistics are
amazingly good. Take my word for it, the results of battlefield surgery
(in relation to infection) are almost as good as civilian surgery do~-ie
with full ceremony. (On second thought, don't take my word for it. Write
to your congressman for full details. It will do him good to know that his
constituents are on their toes and that they expect him to be, also.)
29 Described by Dr. William J. Ledger, of the University of \Iichigan
Nledical Center, in Hospital Practice, July, 1968, p. 34.
32
Tradition extends to surgical technique itself. Laborious hand work is
still used when advanced machinery is available. 'iL recall the furor
aroused at a medical convention when surgeons from the Soviet Union
demonstrated their stitching machines for the sewing together of blood
vessels; practically none are used to this day in the United States. A
stapling machine useful in stomach surgery is in routine use in Japan, but
in only a few hospitals in this country. (In one of those hospitals, the
surgeons wear belts and suspenders-they suture the same area after the
stapling is completed.) In 1955 a Dutch surgeon, Dr. fete Boerema,
introduced a snaptogether plastic button for gastrointestinal operations;
it saved time and, better yet, could be applied in areas where ordinary
sewing was extremely difficult, if not impossible. The device was reported
on in the Annals of Stirgery; it was no secret. Fifteen years later it was
first used in this country.
But conservative and traditional as surgeons are, they are simultaneously
innovators and radicals. Patieiits used to be kept in bed for a week after
an operatioii; it took a world war with its concomitant shortage of
doctors, nurses and hospital beds to bring about acceptance of the idea of
early ambulation. Then the race started to see how soon patients could get
up postoperatively; -it is now agreed that he may (not can) walk as soon
as he recovers from the effects of the anesthetic. Formerly surgeons
refused to operate on cases where cancer had spread through viscera,
pelvic bones and spine; now, with improved techniques, they deligbtedly
report additions to the pelvic exenteration operation (in which parts of
the bowel and bladder and all pelvic tissue are removed) by doing
translumbar amputations which leave the patients in a worse condition than
the illusionist's half-woman, the cancer prestimal)ly having been
eliminated, but the life left not worth living. Dr. Michel Garbay,
reporting on a case (with liorror-indticing illustrations) in which he
performed this operation (La Presse M~dictile, 1967, 76: 559) acknowledges
his debt to American surgery by citing five cases done in the United
States, dating from 1962. The total number of cases is now seventeen.
Another illustration of bold surgical technique was the recent separation
of Siamese twins joined at the iiii(lliiie, with three legs (one with two
feet) jutting out fi-oiii the sides of the body. In an operation requiring
six surgeons and lasting twelve hours, the twins Were separ~tted and
remained alive. But not exactly well. To quote one of the surgeons (name
on request), "No one should look at the separation as leaving two normal
The Medicine M
children either anatomically or physiologically. They will need orthopedic
surgery to bring down their good legs, and a prosthesis will have to be
fitted to the other side. They have permanent colostomies, and the
urethral function remains to be determined ......
The greatest surgical achievements have been in the field of
cardiovascular surgery leading up to the sangliinary orgy of cardiac
transplants. The drama of transplanting a heart from one individual to
another (or perhaps the publicity attendant on Dr. Barnard's initial
success) spurred surgeons to such unreasoning levels that the Board of
Medicine of the National Academy of Sciences felt constrained to set up
comprehensive guidelines for the procedure. (One guideline was to make
sure that the donor was dead!) It warned that cardiac transplantation was
not an accepted form of therapy but a scientiflc experiment. Furthermore,
although there may be some uncertainty about when the donor will die or
has died, there is even more uncertainty about the ultimate fate of the
recipient. TI-te heart transplant is not the same as a kidney transplant;
if the latter fails, the technique known as dialysis is still available
for the prolongation of life; but if the cardiac transplant fails, woe!
To be fair to the medical profession, I must say that from the very
beginnings of cardiac transplantation, physicians have voiced their doubts
about the procedure. As time goes on and the public becomes more informed
about the uncertainties of the operation, the voices become louder. Dr.
George E. Burch, president of the American College of Cardiology, says, At
what point can the medical man, in good conscience and given the wide
range of drug and surgical therapies available, tell his patient that
medicine has nothing to offer him except an experimental 4nd hazardous
procedure? ... To compound the problem, the patient may already have been
persuaded by publicity in the mass media that transplantation is his real
salvation . . . 40,000 patients could be restored to a useful life at far
less cost and without the immunologic problprns of transplantation." And
Dr. John J. Hanlon, past president of the American Public Health
Association, wryly comments that the $60,000 over-all cost of one heart
transplant with dubious chance of success could be better used to train
four physicians who could treat thousands of patients; he suggested it was
time to stop the narrow thinking typified by such surgery and apply the
money to preventive medicine.
The arguments about cardiac transplants brought out some interesting
statistics. A study of congenital
Members of One Body
(present from birth) heart disease in adults (237
cases) showed that only 37 had died at the time of the
survey and 19 of those had died from surgery done to correct the defect.
Another study, of the causes of death of 109 patients with cerebrovascular
disease from narrowed carotid arteries, showed that 57 had died while
under medical treatment and 52 after surgical treatment, no great
statistical difference. Dr. Barnard, defending himself at a surgical
congress, pointed out that surgeons operate on children with atrial septal
defects although life up to fifty or sixty years is very possible in such
cases. Another speaker commented that it was often smarter to leave well
enough alone rather than tamper with the anatomical peculiarities a
patient had, because the cost of attempting correction might far exceed
the price of a judicious do-nothing approach. Among those costs (other
than the hazard of immediate death on the operating table or shortly after
the operation) is permanent brain damage from anoxia or fat embolism. (Fat
embolism is a condition in which globules of fat lodge like clots in an
artery.) Dr. J. Donald Hill of the Pacific Medical Center in San Francisco
says flatly, ". . . The vast majority of patients leaving the hospital
after open heart surgery have varying degrees of fat embolism in their
brains."
About cardiac transplants for themselves, doctors answered a poll in no
uncertain terms. Fiftythree per cent of respondent cardiologists (218 in
all) would not consent to heart transplant surgery if they had advanced
heart disease with a poor prognosis; an additional 20c/c, were
undecided.'o
The problem of transplants is not one of technique. No one can deny that
the surgical feats are amazing. What is too bad is that they are so good
that surgeons, in their zeal to show their skill, go ahead before all the
problems of tissue-matching and tissue-rejection have been solved. Even
after the death of Dr. Blaiberg, overoptimistic comments appear in the
surgical literature, to the point where such science-fiction stories as
brain transplants are discussed. One doctor in Texas not too long ago
performed what he called an eye transplant. If he did what the press
claims he did, only charity can excuse him for his ignorance of
physiology. Experiments with drugs are usually so carefully circumscribed
and controlled since the thalidomide fiasco that one is puzzled by the
freedom with which surgeons experiment and by the equal nonchalance with
which patients submit to the operations.
Let's forget about cardiac transplants. Here's a better example of
surgeons rushing in where angels fear to
tread. There is a psychiatric (yes, sir-psychiatric) condition in which
the patient feels he/she would be happier were he/she to belong to the
opposite sex. I do not refer to true hermaphroditism (often curable and
actually cured by operation) but to transsexualism. Reputable surgeons do
not hesitate to offer their services to men (not women-because
constructing an erectile penis is an impossibility) who want to have their
genital organs removed and an artificial vagina constructed. Christine
Jorgensen (real) and Myra Breckenridge (fictional) are examples of what
can be done. What can be done-but should it?
Should it? Suppose you were a doctor with
around 350 pounds). You could hospitalize
restricted diet, and assure him that more
Or-you could hook up the beginning of the
bowel, thus bypassing the area where food
an obese patient (fat, very fat,
the patient, put him on a
than 100 pounds would be lost.
small intestine to the large
absorption takes place. The
patient could then eat whatever he pleased-hot fudge sundaes, whipped
cream cakes, home fried potatoes-and lose weight anyway. Who needs to diet
if such a marvelous procedure is available? But don't run yet to the
nearest surgeon. First remember that the operation is physiologically
unsound and then read about the damage it can do to the liver.~l
Which brings us to the difference between surgical achievements and
progress. Dr. Eddy D. Palmer (another Voice of Authority) castigated a
meeting of surgeons for their lack of distinction between the two. It
would be difficult to show, said he, that a patient with cancer of the
stomach in 1966 would fare better than a patient with the same disease in
1866. He also pointed out that the surgical treatment of duodenal ulcer
reflected not only the failure to add much to our knowledge of
gastroduodenal physiology but also showed technical regression from time
to time. New operations were continually being put forward, hailed as the
final answer and then quietly discarded as disillusioning evaluations
poured in. just as in cardiac transplantation, the techniques outstripped
the knowledge of physiology.
30 Reported in the Journal of the Wedical Society of New Jersey,
May, 1968, p. 223.
31 Drs. E. J, Drenick, F. Simmons, and J. F. Murphy, reporting in
the New England Journal of Medicine, 282:829, 1970.
34
The Medicine M
I get the feeling that maybe there are new dance steps, but the rhythm and
results are the same.
But don't blame the surgeons alone! They're just keeping up with the
public demand for brilliance and breakthroughs. People are impressed by
surgery because actions speak louder than words. Manual dexterity, like
prestidigitation, is more spectacular than the mental processes needed to
arrive at an accurate diagnosis or sound surgery. In medical school I had
a professor who said, "Truth is revealed and mystery dispelled by the use
of the aseptic scalpel." One of his medical colleagues laughed when the
aphorism was repeated to him and asked, "What about a hot, tender, swollen
shoulder joint? Would he operate first and think later?"
The medical man did not consider that people want a definitive solution to
problems, not long, drav,,n-out treatments, and what's more definitive
than transplants, excision or amputation?
Think twice-maybe three times-when a doctor recommends a surgical
procedure for you. Ask what are the possible complications, what are the
chances of dying from the operation, and most important, how much longer
will you live comfortably if you're not operated on. That's what I did.
5.
A SIMPLE SOLUTION
A man had a fungus infection of the toes (athlete's foot), especially
between the webs of the third aud fourth toes on each foot. Three weeks of
treatment cleared the infection temporarily. When it recurred, the fifth
toe on the right foot was amputated and the third and fourth toes sewed
together, eliminating the web. The patient was so pleased with the result
that he wanted the same operation done on the left foot, but by this time
more conservative therapy had controlled the infection and the surgeons
did not operate.
The surgeons learned from that first case. What? Not that conservative
therapy might help, but that in their next case they'd better do both
sides at once. They did. They removed all except the great toe on each
foot. End of disease.
The above is true. It was reported in the Achives of Derinatology, 99:6.
By analogy, recurrent headaches can be permanently eliminated by the use
of the guillotine.
6.
"Better a snotty child than his nose wiped off."
George Herbert, Outlandish Proverbs
Serenely pursuing the mysteries of their craft, the otolaryngologists
(nose, throat and ear men) pay no attention to the crude television
pictures of sinus cavities and blocked-unblocked nasal passages. They used
to be eye, ear, nose and throat specialists, as though proximity of
structure had relation to diagnosis and therapy. Imagine them treating
brain tumors by the same reasoning! Common sense finally prevailed. The
specialty underwent fission into ophthalmologists and otolaryngologists.
The ENT men feel secure in their profession; they have no need to unbend
to the fickle public. They know that as long as women talk and men blow
their noses and children have sore throats their services will be called
for.
They don't resist change. Not at all. When optical engineers developed an
operating microscope, the otolaryngologists gladly used that instrument
for science-fiction types of manipulation of the tiny auditory ossicles in
the treatment of otosclerosis, a form of deafness. When other engineers
improved audiometers, the otolaryngologists took over to improve their
diagnostic techniques.
Such an ecumenical spirit can only be commendeduntil one looks carefully
at the practice and discovers that the addition of the new and helpful has
not necessarily meant the discarding of the old and harmful.
Take such a well-known instrument as the otoscope, for example. You know
that cute little searchlight device with the small earpiece that the
doctor uses to examine the ears. With that device the doctor can see the
eardrum and can tell whether it's inflamed. But if it isn't-well, he's
doing his best to inflame it. I quote: "The study showed beyond a
reasonable doubt that it is possible to induce purulent otitis media
(pussy inflammation of the middle ear) through excessive manipulation in
the ear canal. It is little wonder, then, that there are many who consider
the use of the direct otoscope a curse rather than a blessing." Poking at
the delicate tissues of a child's ear canal (and who can prevent poking
when the little darling is squirming and fighting?) irritates those
tissues; if the earpiece is not scrupulously
32 Dr. H. Bakwin, "Pseudodoxia Pediatrica," New England joumal
of Medicine, 232:691, 1945.
Members of One Body
clean, infection supervenes. But doctors learn, even if it does take them
a long time. In 1969 disposable earpieces came into fairly general use.
The otolaryngologist has a special place in the social maturation of
children. Long before any of the other rites of passage (like wearing a
training bra or getting a driver's license) are undertaken, he initiates
the child into painful health-consciousness, one of the desiderata of our
society. He removes the tonsils and adenoids.
Tonsillectomy, with its concurrent adenoidectomy and its equally
concurrent morbidity (illness) and unfortunate mortality, is the operation
most frequently performed (except for those procedures associated with
childbirth) in the United States today. It accounts for 100 to 300 deaths
annually in this country. Those figures are not mere statistics-they're
made up of the wailing of mothers for their lost children, children who
died as the result of an "elective" operation. Who elected to do it? The
parents? The doctor? That's mortahty. N4orbidity includes the 42.8c/c of
children losing IO(IC of their blood volume and the 3~~c losing more than
25~',, leading to, in some cases, tying off of the external carotid artery
in the neck (a formidable operation with potential serious aftereffects)
and, in others, to more than five transfusions. Furthermore, the operation
has profound and bad psychological effects. Consider-a child is separated
from his parents, put in a strange bed, stuck with a needle and then
terrorized by having a mask clamped over his face so that be must breathe
a suffocating gas. No wonder the psychiatric literature is full of
evidence that childhood tonsillectomy may cause night terrors, abnormal
dependency on parents and deep hostility toward doctors.
Why is the operation done? Ask the doctor who advises it or the one who
performs it, and the answer will be double-talk, if he bothers to answer
at all. More likely you'll be looked at as an anarchist radical who
carries a Molotov cocktail in one hand and a copy of Chairman Mao's
teachings in the other, one of those wise guys who dares to question the
eternal verities.
Actually, doctors themselves (including a few, a very few
otolaryngologists) have long been doubtful of the value of tonsillectomy.
The consensus is that tonsils are being removed merely because they're
there. After all, no one knows their function; therefore, no one can say
with assurance that their removal is harmful. "Enlarged tonsils" is a
statement, not a disease; it is in the category of a retrousse' nose or a
receding chin. Doctors agree that tonsillectomies can be done for any
condition except acute tonsillitis; in that case it is contraindi
cated. In other words, tonsillectomy should be done in the absence of
tonsillar infection; the operation is safest when done on perfectly
healthy individuals. Dr. Bakwin (quoted previously) reported that no
correlation existed between a child's health status and recommendation for
the operation; bow the physician felt about it was the decisive factor.
Ah! I hear you say, but tonsillectomy is a propbylactic measure, not a
therapeutic one. Removing those lymphoid blobs from the throat will
prevent colds, rheumatic fever, sore throats and a dozen other ailments.
Not at all. Survey after survey, study after study, year after year, all
have demonstrated that cliildren whose tonsils have been removed are no
better off in health than before the operation, that rheumatic fever is
not prevented, that indeed no determinable value adheres to the operation.
One of the first controlled community studies on
tonsillectomy (in Rochester, New York, in 1922)
showed it bad no effect on the recurrence of otitis, bronchitis,
laryngitis, pneumonia or rheumatic fever; yet this past year one-third to
one-fifth of all children hospitalized in that same area were admitted for
tonsillectomies!
A more recent survey (1968) says the indications for the operation should
be severely limited to children between the ages of five and seven who
have persistent nonallergic nasal obstruction from very large adenoids or
who have tonsils so big that they cannot swallow. The operation is
worthless "for repeated colds, chronic cough and other respiratory
diseases, or anorexia [loss of appetite]. With antibiotics, there is
little need for the operation in patients with a history of rheumatic
fever'or nephritis . . ."33
And a professor of otolaryngology at Johns Hopkins University, Dr. Donald
F. Proctor, says, "We now know that recurrent tonsillitis is generally a
benign disease to be expected during one or two years of the average
child's life. We believe that the presence of tonsils and adenoids during
early childhood may play a role in the development of normal [immune]
defense mechanisms . . . if each child is treated more consideratelv,
fewer psychoneurotic complaints will complicate the lives of adults."
To illustrate the unthinking acceptance of tonsillectomy as a procedure of
value, first consider that in
33 Dr. Robert J. Haggerty, of the University of Rochester, N.Y., in
an article in Pediatrics, 41:815.
'36
12'~ of the patients operated on, the complication of post-operative
bleeding occurs and then ask why the operation is performed on hemophiliac
patients who are almost guaranteed to bleed. Yet it is done. And
in,aenioi-is doctors resort to novel methods (cryosurgery, for instance,
done by Dr. Hans von Leden of the Uni\-ersity of Southern California at
Los Angeles) to obviate hemorrhage. A thinking person might say-why do it
at all?
Really, why are tonsillectomies done? The obvious, but incorrect, answer
is venality. Again I hasten to rise to the defense of my colleagues. The
same studies I lian,e mentioned also show that economic considerations
play no part in recommendations for the operation; clinic and welfare
patients have proportionately as many tonsillectomies as those able to pay
for that dubious service.
Tonsillectomy is done because of mental inertia, because a break with
established ritual is emotionally painful, and because (very important)
parents feel that they would be depriving their children of the benefits
of good medical care were they not to offer them up to the tonsillar
guillotine as to Moloch. (Guillotine is not used metaphorically; it is the
name of an instrument.) "Ritualistic surgery" is what one eminent
pediatrician calls tonsillectomy. He puts it in the same category as
sacrificial castration or the pubertal knocking out of teeth.
But what if your doctor recommends tonsillectomy for your child?
Immediately you can come to the conclusion that he is either stupid or
mentally lazy. Time to change doctors.
7.
A STUFFY NOSE
Don't get the idea that otolaryngology is a needless specialty. It is not.
The operative cures for several types of deafness have been nothing short
of marvelous, and the recent results in the treatment of cancer of the
larynx equally so.
Even in such a mundane case as a chronically running nose, the ENT man
can often effect a cure by removing what shouldn't be there. People have
strange habits.
Here is a list of what I have removed from the nasal passages--of adults
as well as children:
Bits of rubber eraser Paper clips
Cotton swabs Lima beans (uncooked)
The Medicine Men
A shoelace Crayons Tin foil Bolts and screws
Newspaper Toothpaste caps A piece of frankfurter
Assorted nuts (metal and edible
An ENT friend of mine added to the above. He removed a beetle, watermelon
seeds (ungerminated) ) cigarette butts, popcorn and a jack (playing, not
automobile).
8.
"Birth, and copulation, and death
That's all the facts when you come down to brass tacks."
-T. S. Eliot, "Sweeney Agonistes"
Unlike the EENT men, who split off the first E, the obstetricians and the
gynecologists have amalgamated. (Pronounce gynecologists as you please.
Authorities differ. Classicists say Guy; modernists can't make up their
minds between Gin and Jine.) The two groups have united not because they
deal with the same anatomical parts but because of the falling birth rate.
It stands to reason that in the nine-month interval between conception and
delivery the obstetrician should do more than sit and twiddle his thumbs
while waiting. He might just as well be doing something useful like
repairing the tissues damaged in a previous delivery or like making
fertile women infertile or the other way around. (I say he not because I
am a male chauvinist, but because the number of women practicing medicine
in this country is negligible, deplorably so. I can be smug in my
deplo'ring--oDe of my daughters is a physician.)
The OB-GYN man is surrounded by a mystic aura compounded of fear, male
hostility, female adulation and a peculiar glamour. The fear is mixed with
awe. It is understandable. It is a primitive, almost reflex, response to
one who seems to bring forth life "between corruption and comiption," as
St. Augustine said. It is the mouth-open wonder at one who touches with
impunity the secret parts, at the magician who disregards the lightning of
parental and societal disapproval, at the fearless prober of the mysteries
of the Bona Dea. The hostility of the male is derived from envy of
privileged voyeurism, from his feeling of exclusion from an area in which
he has a vital interest, and from a mistrust of the doctor, a mistrust
fostered by the lurid imaginations of the doctor-novel writers. The
adulation of the female is also comprehensible. On the
Members of One Body
surface, it occurs because the doctor actually helps women in trouble and
pain. Analysts have said it is a socially acceptable surrendering to
incest fantasies; more skeptical observers consider it a barely disguised
lubricity, for with whom else could women indulge in conversation that
would make the Wife of Bath blush?
Glamour attends the picture of the frantic racer with the stork, the
weary, haggard doctor patiently comforting the woman in travail, the
sympathetic listener to the woes of womankind. Besides being a healer, the
doctor is used as a father-confessor, a confidant, and an advicegiver.
Small wonder then that the heads of so many OBGYN men are turned. They
undertake to merit the confidence placed in them. They forget the
limitations of human knowledge in their field. They assume the mantle of
divinity. They proceed to interfere with nature in the name of science and
by virtue of the authority vested in them by the states in which they
practice.
First, they tried to get rid of the curse of Eve. "No more pain!" became
the slogan. Under their expert miiiistrations the woman in labor was to
expect no niore than slight discomfort and was to awaken refreshed and
chipper after her delivery, with her baby at her side. Chloroform, etlier,
"twilight sleep," newer and ne",er synthetic drugs for inhalation and
injection were iiitroduced and acclaimed but not discarded as their danger
for mother and infant became known. In the century since Sir James Simpson
gave Queen Victoria chloroform for her accouchement, obstetricians came to
the conclusion (which a little forethought and attention to the facts of
physiology would have shown) that anything that put a woman to sleep would
also have the same effect on the baby in her womb and would tend to
prolong her labor by diminishing the strength of her uterine contractions.
Spinal anesthesia, so useful in surgical operations, was then tried but
found to be too dangerous for the mother. In 1941 caudal anesthesia, a
variant of spinal anesthesia, was introduced and for years was held to be
the ideal agent. Unfortunately, the technique for its use was complicated
and equally unfortunately, it carried with it a small but definite
mortality in the mothers (and a small-if 10.6(/c is small-problem of
resuscitation in the newborn child) .3-' The obstetricians met the
challenge directly. They announced that natural childbirth was the best
method and rejoiced to see the new generation of mothers doing breathing
and relaxing exercises in anticipation of the grand event.
Some doctors kept right on'trying, however. Back to
37
unconsciousness they went. (A catty person might say consciencelessness.)
Bigger and bigger doses of sedatives were used. Then in 1968 it was
reported that large doses of barbiturates given intravenously not only do
not have a good sedative effect on the mother but they depress the
breathing of the newborn infant. So-the dose was reduced and a
phenothiazine compound was added; that was a little better for the baby
but provided less sedation for the mother. You'd think now the method
would be discarded, wouldn't you? "No," said the well-meaning doctor,
wiping his sweating brow, 11 we gotta do something." So-back he went to
the heavy sedation, making the mother unconscious by intravenotis doses of
the narcotic, meperidine, plus scopolamine, and then a few minutes before
delivery he injects nalorphine (a pbarmacologic antagonist to the drugs
be's used). Result: less depression for the baby but an increased
incidence of acidosis. Conclusion"The normal healthy infant born under
this type of medication can withstand the pbarmacologic insult; however,
the child who is compromised in any way seems better off delivered by
less. injurious metbods."'-~,
Hypnosis and stiggestion are also used. Old women in primitive societies
practice witchcraft in difficult deliveries. Lest that last be interpreted
as a snide remark, let me hasten to say that in my own practice I used
suggestion with good results. I even wrote a paper on it, to which I shall
modestly give no reference.
So now natural childbirth is fashionable. But the
American version of that process is not exactly like Eve's parturition. It
presumes a little help from the obstetrician. The patient is no longer
numb from the navel down, but Baby's entrance into this vale of tears is
speeded by cutting Mother's perineum and applying extractive apparatus to
Baby's head.
Since the doctors couldn't stop the pain of labor, they
tried their hand at shortening its duration. That bad advantages for the
doctor, more so than for the patient. He didn't have to sit around
waiting,- until the goddess Lucina settled down to her job. He used
quinine, astor oil, hot enemas, pituitary snuff, enzymases, forceps, and
vacuum extractors. Of course, presumably delivery should not take place
until the maternal tissues and the delicate fetal head have had time to
adjust to each other. But progress is progress and if art can improve
35 Doctors R. B. Clark et al., in Obstetrics and Gynecology, 153:30,
January, 1969.
34 Drs. A. 0. Lurie and J. B. Weiss, reporting in the American
Journal of Obstetrics and Gynecology, 103:850, 1970.
on nature, why not? Furthermore, if, as says the American College of
Obstetricians and Gynecologists, "obstetrical care, including delivery, is
a surgical procedure," why not schedule a delivery just as surgeons
schedule an operation?
That can be done and it is done, especially when the doctor is busy. On or
about the calculated date that the baby is due to arrive, the patient goes
into the hospital. She is prepared to be rid of her burden. Drugs are
given to induce labor; the membranes around the baby are punctured instead
of waiting for their inevitable rupture; instruments are used and surgical
incisions made to facilitate the delivery of the future President. A nice
clean procedure. The hospital is happy, the patiei)t is happy, and best of
all, the doctor is happy.
Maybe all the happiness makes up for the disgraceful position the United
States has in maternal and newborn mortality lists. In 1950, eight out of
every 10,000 deaths were of women in childbirth; in 1966, the iiumber
dropped to three. Good, huli? Not on your life! "The low prevailing
materiial mortality rates have led to a philosophy that an irreducible
minimum has been reached and that the few remaining deaths must be
inevitable ... Tliree-quarters of the remaining obstetric deaths are
preventable . . .""' The authors of that statement charge that ox,ertise
of uterine stimulants during labor and the too-freqtteiit resort to
Caesarean section are the majot causes of this morality. NNitli all this
country's wealth and far-flung medical services we stand eleventh on the
international maternal mortality list, just below Belgium. Sweden is
first, with exactly half our materiial mortality,
One of the most seiisiti\,e iiidices is the neonatal mortality rate,
deaths under 28 davs of age per 1000 live births. 111 1966, Sweden was
first, with a rate of 10.3; we were tied with CzecliosloN,akia for
twentieth place, preceded by Singapore, Jamaica, Bulgaria, Romania, etc.
Some things are worse than death. Consider what happens as a conseqtieiiee
of interfering with normal childbirth. As long ago as 1861 it was noted
that cuttiiig off or down on the oxygen supply to the baby in the process
of being boi-ii resulted in neurologic and mental disorders. That ol)ser\ation kept being confirmed and disregarded. The disregard came from
skeptical and scientific doctors who said, "Prove it." So finally it was
proved by Dr. (Pli.D., not NI.D.) NN'indle of the New York University
iniedical Center. He concluded a popularization in the Scieiitific
Aiiiericati of his findings thus, "there is reason to believe that the
The Medicine Men
number of human beings in the U.S. with minimal brain damage due to
asphyxia at birth is much larger than has been thought. Must this continue
to be so? Perhaps it is time to re-examine current practices of childbirth
with a view to avoiding conditions that give rise to asphyxia and brain
damage."
Anything that slows the placental circulation reduces the blood supply
(and hence oxygen supply) to the baby's brain. Very strong uterine
contractions will do that. Drugs that depress the mother's circulation
will do the same. Pain-relieving drugs that pass through the placenta' to
the baby, especially drugs related to morphiiie, have an inhibitory effect
on the baby's respiration, so that spontaneous breathing after birth may
be delayed or so shallow that insufficient oxygen gets into the baby's
lungs. Pressure applied directly to the baby's head may also depress
circulation by a reflex as well as by a direct action. If the neck of the
womb (the cervix) is excessively rigid and the protective bag of waters is
not present, the baby's head acts as a battering ram with every uterine
contraction. If forceps are applied, pressure is obvious and vigorous.
Vacuum extractors almost always cause subcutaneous bleeding under the
scalp; why should one not expect tiny bleedings in the brain under the
yielding bony structures of the baby's skull? Unassisted (and unimpeded)
childbirth has its own prol)lems-those of maternal discomfort and
unavoidable pressure on the baby's head. Why add to them?
Expectant mothers should remember that babies were born before the advent
of obstetricians, that pregnancy and childbirth are not diseases, and that
therefore the more natural the labor, the better the result for mother and
newborn infant. Beware the doctor who promises a scheduled delivery and a
painless labor! And be equally wary of the doctor who freely prescribes
drugs to alleviate the minor discomforts and tensions of pregnancy.
They may make you feel better but may damage
your baby. It has been demonstrated that barbiturates
and tranquilizers may cause changes in the fetus that show tip in later
life as learning and behavior problems;'7 tetracvcliiies cause
discoloration of the child's teetli; some steroids affect the sex organs,
etc., etc.
In Israel obstetricial nurses deliver 90~Ic of the
"I Dr~. Otto C. Phillips and jaroslav F. Hulka, "Obstetric MortalitN,,"
in Atie5tliesiolog!l, 26:435, 1965.
37 Dr. Conan Kometsky, of Boston University, in a paper delivered
at the American Medical Association meeting of December 1, 1970
Members of One Body
women in labor. "Our doctors are reluctant," says Dr. Wolfe Z. Polishuk of
Hadassah University Hospital in Jerusalem, "to have our mothers
unconscious during delivery. We use natural childbirth and avoid
anesthesia in normal deliveries ... Only 2r/c of our [vaginal] deliveries
are with forceps. . . ."
Swedish doctors say that their enviable positioii arises from the fact
that nurse-midwives do all normal deliveries. They stay with the patient
from the time she enters the hospital until she is de]iN,ered; they are
not permitted to use anesthesia; tliev are not allowed to rupture
membranes (the bag of waters), induce or hasten labor, or make use of any
operative techniques.
Then why don't Americaii Nvomei-i use trained midwives? Because when they
N,,,aiit a priest, they're not satisfied with a deaconess. They feel it's
beneath their dignity to have a motherly midwife rather than an abstracted
obstetrician in a litirry to get on with his second job.
That other job is primarily, to judge from the volume of reports and
publications on the subject, to guard the female sex from two presumptive
evils: the menopause and reproduction. The menopause, with its
accompaiinling fearsome old-wiN,es' t ' ales aiid its actual physiologic
changes, is a bogeyman that must be CODjtired aNN,a,,-. The prevention of
conception is not only the iiil)orii right of women, but it has also now
become a patriotic duty.
Menstruation, "the curse," would gladly be given tip by women were it not
that its disappearance signals to them that they have reached the final
milestoi-ie of their lives. From that point on everything goes downgrade.
Bat suppose some sorcerer held out to them the proiiiise of eternal youth,
or at least permanent middle age? Would they not flock to his cave for
that wonderful elixir? Would they not take it without thought of the
aftertaste? A sorcerer would sell it to them without aiiv warning, but
should a gynecologist?
The female sex hormone, estrogei-i, originally used as replacement
therapy in more or less pathologic postmenopausal states, such as senile
vaginitis and excessive flushing, has recently been touted in the
Ni7omen's magazines and widely prescribed by doctors in response to the
demand by women for protection against the changes that occur in them as
the years go on. Enthusiasts claim it can prevent wrinkled skin, gray
hair, loss of libido, constipation, "liver spots," ostcoarthritis,
depression, irritability and a dozen other complaints. Those claims are
not substantiated by carefully controlled studies. The manufacturers of
estrogens, wary of
39
the Food and Drug Administration, are more cautious in their adxertisemeiits; for example, one says, "in view of the accumulating evidence
that estrogens are protective against pretizattire [my emphasis]
degenerative metabolic changes, within recent years the continuous use of
estrogeii in the aging female has been looked upon with more favor than in
the past." The quotation is from a package iiisert for information of
physicians (Estin),I, maiitifactured by Sclieriiig).
The informatioiial iiiserts in the packages also warn, however, that
proloii,,ed use of estrogen may iiibibit the secretion of certaiii
hormones of the anterior pituitary gland. That should gi\~e you patise.
Scientific observatioii has deiiioiistrated how fearfully and wonderfully
the human body is made and how delicate is its physiologic balance.
Iiiterferiiig at any single point with its mechaiiisiii or its (IN,iiamics
may cause changes far distant froiti the original poiiit of interference.
For example, if an endocrine stil)staiiee naturally produced in the body
is given artificially, the glandmaking that liormone shtits itself down.
In the case oi 'estrogen,, the aiiterior pituitary glaiid stops secreting
its ovarianstimulating liormoiie. Once that internal governor controlling
estrogen secretion is i)ot working, who can itid(,-e what is the right
dose to give? An excessive use of estrogenic liormoiies may produce
oversecretion of iiiticus at the iieck of the womb and thus a seco-~idary
iiiflammatioii of that area. Furthermore, so well docuiiiented are the
fiiidiiigs that estrogens cause stimtilatioii of breast tisstie and of the
tissue lining the uterus that the package inserts must carry the warning
to pliNIsicians that estrogeiis should not be used in women XN-itli a
personal or familial history of mammary or genital cancer.
Dread word! Is there any basis for worrying that estrogens can cause
cancer? Yes, there is. Dr. Roy Hertz, Chief of the Reproductive Research
Board of one of the National Institutes of Health at Bethesda, Maryland,
says so quite bluiitly." After discussing the experimental data on the
carcinogenic action of estrogens, when asked whether the prolonged use of
estrogeiis in wonien before the menopause could eventually cause cancer,
he answered, ". . . We are ill advised to ignore the mass of observations
clearly relating .
311 Interviexv reported in Ca-A Cancer Journal for Clinicians, (pub
hshed by the American Cancer Society), March, 1968.
40
estrogen. to the pathogenesis of breast cancer in both man and animals."
In response to the question of why estrogens were so extensively
prescribed by the medical profession, he gave an evasive answer, one
ftnplying willful ignorance on the part of the doctors. He also commented
that cancer of the uterus was a possible delayed afteteffect. There is
much more evidence than that interview for the danger in using estrogen;
you can find plenty of references in any text book on gynecology or in the
book; The Pill, by ~Nlorton Mintz, publisbed in Boston in 1970.
The Pill has 8angers. Why shouldn't it have? The Pill has a profound
effect on the endocrine system. It prevents ovulatioti by inhibiting the
output of gonadotropins (ovary-stilmulating hormones) from the pituitary
gland. It also affects the skin, the adrenal glands, the liver, the utefus
and who knows what else. It may be (and has been) the cause of jaundice
and other liver disturbances, the enlargement of fibroid tumors, abnormal
increase of facial bair, the retention of fluid in the body leading to a
gain in weight, sometimes kidney or heart strain, swelling of brain tissue
(aggravation of epilepsy, rni~kaine, possibly mental changes), thyroid
disturbances, excessive clotting of blood, stunting of growt~ in ieenagers, and-wby go on? The longer the Pill is used and the more its action
on the female organisni is ihvestigated, the more horrendous does it
appear. And if you think that I made up that list of perils of the Pill,
you're mistaken. I shortened it from the one the Food ~nd Drug
Administration requires in the package in serts. Every advertisement to
doctors about the Pitl carries A full page of fine-print warnings about
adverse reactions, contraindications and side effects.
Why all the side effects? Because prolonged treatment with ovi-ilation
inhil)itors interferes with a woman's normal hormonal balance. Because
inhibiting the action of the pituitary gland in one direction inhibits it
in others'. The result in some cases is actually a permanent suppression
of ovarian activity even after the use of the Pill is discontinued. The
woman no longer menstruates and becomes sterile. In other cases, while
fertility is unimpaired, the ability to secrete milk after delivery is
reduced so that the mother cannot breastfeed her baby. In still other
cases, the Pill, being a steroid hormone having an effect on the liver,
results in a folic acid deficiency type of severe anemia.
Three studies of the effects of the Pill are still going on. The latest,
by Dr. Herbert Gersbberg of the New York University Medical Center, warns
that the Pill may cause high concentrations of cholesterol in the
The Medicine Men
blood, presumably a forerunner of hardening of the arteries. Another
report agrees with that of a previous survey conducted by the National
Institutes of Health, which in turn supported that of a British team.
Since the Pill has been in use there has been a significant increase in
the number of deaths in women between the ages of 20 and 44 from venous
and puhnonary embolism secondary to thrombophlebitis. That is, abnormal
clotting takes place in veins; portions of the clot break off and are
carried to the pulmonary arteries, where they lodge and obstruct the
circulation in the lung. The annual increases in the death rate have
averaged between three and twelve per cent. Embolism also occurs in the
cerebral arteries; women have had strokes after taking the Pill. When you
consider that strokes in the age period when women are fertile are rare,
you realize that the fancy package contains a bunch of tiny lethal
weapons. Confirmation comes from Doctors Hobell and Nlishell, who found
that in seven of their eight cases of pulmonary embolism in women, the
women had been taking oral contraceptives. The Food and Drug
Administration i-iow requires that the manufacturers of the Pill caution
doctors about the dangers of thrombophlebitis and embolism when it is
used.
The most controversial aspect of the Pill comes from its direct effect on
the uterus. A SloanKettering research team found significantly more
cervical cancer in sitit (localized cellular cancer of the neck of the
womb) in pill takers than in diaphragm users. Dr. NN'ied of the University
of Chicago reported a sixfold increase in positive Pap smears among women
who had taken oral coi-itraceptives. The proponents of the Pill say it is
safe, that the above studies are inconclusive, and that more study is
needed. They all concede, however, that the Pill does indtice changes in
the surface linin,, of the uterus.
1, in not a stick-iii-the-mud reactionary nor the only opponent of the
Pill. Dr. Hugh J. Davis, assistant professor of obstetrics and gynecology
at Johns Hopkins University School of Medicine, says, "It is medically
unsound to administer such powerful synthetic hormones in order to achieve
birth control objectives which can be reached by simple means of greater
safety," and "The widespread use of oral contraceptives . . . has given
rise to health hazards on a scale previously unknown to medicine . . ."
and "It is extremely unwise to officially license, sponsor, and encourage
a long-range experiment, such as we now have in progress." But, as Dr.
Ralph Benson said at a recent meeting, "Women make superb guinea pigs [for
testing oral
Members of One Body
contraceptives]. They don't cost anything, they clean their own cages,
they pay for their own pills, and they even remunerate the clinical
observer."
The dangers of the Pill were finally recognized by the manufacturers of
pharmaceuticals. They didn't take the Pill off the market. Oh, no! They
reduced the amount of hormone in each pill so that the side effects would
be less obvious. But-in order to stop the eggproducing function, there
must still be a dose large enough to interfere with the body's natural
hormone balance!
So when diaphragms and jellies and foams and condoms are available, why do
so many women play a variety of Russian roulette? Because they (or their
husbands) are lazy. Because they have been brainwashed by the vested
interests of the proponents and makers of the Pill. Poor things! They are
children playing with matches, matches supplied by the indulgent doctors
who give them what they ask for.
(I insert here a political note. In Cuba, "The pill is not considered safe
enough for distribution and, because health is not a commodity in Cuba, it
is not distributed."" In the Soviet Union the Pill is neither manufactured
nor imported, according to the Medical World News of January 10, 1970.
"The Western world is their guinea pig for The Pill.")
NVbat about the stii-,,ical qualifications of the gyiiecologists? I quote:
"The requirements of the Board of Obstetrics and Gynecology are inadequate
... for the handling of many of the surgical conditions in the pelvis
which may I)e encountered in the course of gynecologic surgery."1()
Why go on? The glamour surrounding the OB-GYN man would be tarnished were
the adoring women around him to remove their self-imposed suspension of
reason.
8.
A PAINLESS LABOR
I once delivered a woman of a fine baby boy. It was during wartime, when
there was a shortage of anestbetists and nurses, so that she was unable to
have all the benefits of modern medicine. When the delivery was over, she
said to me, "Why did everybody tell me labor was so hard? It's no worse
than having a hard bowel movement."
Now here's a true record, copied from a hospital chart. The attending
obstetrician was a busy man
41
who'd built his reputation on his success at quick, painless deliveries.
Calculated date of delivery: October 5.
(Admittedlv this date is onlv an approximation, I)eing calculated from the
dat'e of the last menstrual period.)
Admitted to hospital: October 7 for elective induction of labor. The
indications for such induction were listed as
(1) Patient's choice.
(All those years of the doctor's training for naught? He lets the patient
decide when she wants to have the baby?)
(2) Past due date for delivery
(A touching proof of the doctor's belief in his infallibility. When he
says the baby's due on October 5, it's due then and that's that.
(3) Favorable cervix
(Meaning that the neck of the womb is already partially dilated and that
normal labor would start soon anyway.)
8:50 A.M. Examination showed that the baby's head was in good position and
the cervical opening was two inches wide. The doctor then ruptured the
membranes. (The elastic bag of waters protects the baby's head, but it is
not so effectix-e a dilater of the cervix as the baby's skull. The hard
pressure of the head will speed up the process of dilation. And bang the
head.)
9:00 A.M. Intravenous infusion of pitocin in glucose solution was started.
(Pitocin is a powerful uterine stimulant; it causes strong contractions of
the uterine mtiseles, thus propelling the babn, onward and outward.)
9:05 A.M. Uterine contractions started fairly strong, coming every one or
two minutes.
(The baby's head is pounded against the cervix with each contraction.)
9:30 A.M. Pains are much stronger and last longer.
(With each coiitractioii the placenta is squeezed upon and less blood goes
to the baby.)
Intravenous meperidine given.
(Similar in action to morphine, the drug was gi~,eii directly into the
bloodstream of the mother to insure
39 Chris Camarano, "On Cuban Women," in Science and Society,
35:53, Spring, 1971.
40 Drs. A. M. Kiselow, H. R. Butcher, Jr., and E. M. Bricker, "Results of
the Radical Surgical Treatment of Advanced Pelvic Cancer: A Fifteen-Year
Study," Annals of Stirgery, 166:430434, 1967.
42
prompt relief of pain without slowing up the uterine
contractions. Some of the drug necessarily passes through the placenta
into the bloodstream of the baby.) Intramuscular promethazine given.
Another sedative, to enhance the action of the meperidine.) 10:05 A.M.
Examination showed the cervix was almost fully dilated and the head was
coming down fast.
10: 15 A.M. Caudal anesthesia started.
(The doctor promised the mother a painless delivery and he will keep his
promise.) 10:28 A.M. The head of the baby was visible at the outlet of the
birth canal.
(The doctor barely bad time to finish the anesthesia!) 10:32 A.M. Delivery
of a 51/2-pound female child that cried after a few good spanks.
(A wonderful delivery! Fast and painless!)
When the baby was a year old, the mother became concerned because of its
slow development. Her pediatrician informed her that the baby was somewhat
mentally retarded.
When the baby was two, she could not stand without support, she could not
hold toys well, she could not even say "Da-da," and she was excessively
placid. A thorough study showed "delayed neurologic maturation and
definite mental retardation."
Write your own moral.
10. "The best of doctors is destined for Gehenna."
Mishna, Kiddushin 4:14
Internists, the epitome of specialists, are what the public ordinarily
thinks of as doctors: men who use stethoscopes, fluoroscopes and
electrocardiograph machines. They take histories, they listen to the
chest, they palpate abdomens. Never, never confuse them with interns. The
latter are important only in their own eyes. An intern is a fledgling
doctor who lives in the hospital, there to complete his education by a
little practical experience under supervision of those older (not
necessarily wiser) than be. Internists are so called because they
specialize in treating diseases of the internal organs. Not quite. They
exclude from their purview the contents of the skull: the brain, the eyes,
the paranasal sinuses. They also are not concerned with the bones, the
male and female generative organs, and the rectum. What's left? Plenty. So
much in fact that
there are specialists in disorders of the bronchial tubes and lungs
(except for tuberci-ilosisthat has its own specialty), the blood, the
heart and major blood vessels, the peripheral vascular system, the liver,
the stomach and intestines, and the kidneys; in addition, there are those
who treat conditions like diabetes, arthritis, allergies, endocrine
disturbances, tropical diseases, obesity, and that hodgepodge called
psychosomatic ailments. The newest subdivision is geriatrics, a branch
which undertakes to repair the irreparable ravages of time.
The interiiist is consi-ilted for a pain in the chest, for heartburn, for
palpitations, for a cough, for swollen ankles, but not for a fever, for a
sore tbroat, for a cold, for a headache or for a stomach-ache. T,-Ie can't
be bothered with such trivia. His mind is on more complicated problems:
are the swollen ankles due to kidney disease, hardening of the blood
vessels, tight garters or the heat? Is the heartbtirn catised by an ulcer
or by too mtich liqtior or I)NI bad cooking" Does the cough result from
heart failure or cliroiiie I)roiicliitis or overheated rooms or an allergy
to the spotise'~' NN'liv bother him with actite illnesses? He's got enough
to do with the other kinds.
An internist differs from a general practitioner in that he does not
deliver babies, opei-i boils, sew up cuts, set broken fingers, or
N,acciiiate for smallpox. In exchange for not performing these services,
lie charges more money for what be does do in the field of diagnosis and
treatment. The Iii-ie I)etween the general practitioner and the interiiist
is so teiitiotis that the size of the fee is often the only feature
distinguishing the two. Not always, however. The internist, in keeping
with his exalted position, holds hip.-iself aloof from the mundane cares
of the patient. He examines dispassionately, gives his opinion flatly and
makes recommendations appropriate to his diagnosis. "Take a sea voyage,"
he may say, or "Do more exercise," or "Don't work so hard.' The
recommendation may be impossible to follow, but that's not the internist's
worry. He has danced the sacred dance, heard the ghostly voice and spelled
out the sufferer's fate. He has done his duty.
He is proud of his results. Typhoid fever is a thing of the past;
tuberculosis has almost disappeared; scurvy is found in text books only.
Of course, a captious critic could point out that improved nutrition,
better sanitation and housing, and above all, enlightened public health
measures have played a greater part than medical practitioners in bringing
about such wonderful results. Maybe so. Pasteur was not a physician, nor
was
The Medicine Men
Members of One Body
43
organized medicine the initiator of mass immunizations.
Nevertheless, advances in medicine have come about, and today medical
doctors are the agents of those advances. Every organ has been
investigated in detail; every bodily function has been examined. Medical
journals bulge with learned papers on all the iUs man is heir to (and
some, like radiation sickness, he inflicts upon himself).
Reading the medical journals is fascinating. Doctors like to report on
what they're doing and why. You never realize what a thorough job the
internists do until you read the complicated mental maneuvers they go
through to establish a diagnosis and the elaborate justifications they
give for their treatment. They're not always serious. They kid themselves
about their antics; they're not all taken in by the magic. In the April 1,
1968, issue of the august Journal of the Anwrican Medical Association
appears a "Letter from Copenhagen," by Dr. Myron C. Greengold, in which he
describes the diagnosis and treatment of the princess who had the pea
under the mattress (familial thrombocytopenic purpura). The article is
well worth reading in toto. (Contrary to antimedical propagandists, The
Journal of the American Medical Association is a lively, literate
magazine, much better than many sold on the newsstands. )
The very thoroughness with which the internist works makes one wonder. Is
he doing all those fancy tests because he needs the information from them?
Or because he fears being criticized by his colleagues as heterodox were
he to omit any one of them? Or because there is danger that a disgruntled
patient will accuse him of scanting the ceremonies?
The last is ever-present in his mind. Lawsuits for malpractice increase
yearly in this country not because doctors are mistreating more patients
but because patients and their families demand a surety of cure that they
would not think of demanding in answer to a prayer. Doctors are human;
they make mistakes. They should be forgiven. But they are not. Why aren't
they? The answer lies in anticlericalism. Where the Church is strong and
an arm of the state, the rebels and the frustrated and the philosophes see
in that institution the cause of the ills of society. Where (as in the
United States) the churches are respectfully ignored as Musical Banks, a
sort of secular anticlericalism takes over. One of its forms is anger and
a desire to get even with the practitioners of the mystic art of healing.
When charms fail, when unpredicted disaster strikes, when
the well-fed augur misreads the omens, then resentment flares, not
against the gods, the authors of calamity, but against the intercessors
and mediators between Olympus and Earth. A man walks out of a doctor's
office after a routine check-up and drops dead. Who's to blame? The
doctor. A constipated woman develops an intestinal obstruction. Who's to
blame? The doctor. Who else? Post hoc, ergo propter hoc has always been
popular.
So-the doctors become overcautious. Like scribes inditing a Scroll of the
Law, they are circumspect with every jot and tittle. They take
electrocardiograms, needed or not, lest they be accused of neglect; they
prescribe potions for every symptom lest they be charged with indifference
to the needs of the patient; they check and recheck their findings and
hedge their prognostications lest they be denounced for overweening
confidence in their own abilities.
Somebody has to pay for all that extra effort. Guess who?
Internists are big on periodic health examinations. What they say sounds
rational and very scientific. Get a check-up every six months or every
year and you'll nip in the bud any incipient disease. Would that were
true! It isn't. Dr. Gordon S. Siegal of the United States Public Health
Service says sadly that periodic health examinations have been greatly
overrated. Even strong advocates of those examinations (in a survey
conducted in 1970) say they seldom find unexpected disease in presumably
healthy adults. When they do, the disease most frequently found is
diabetes, a disease detectable by a simple urine test. Dr. W.K.C. Morgan,
Associate Professor of Medicine at the West Virginia University School of
Medicine, wrote a stinging article entitled "The Annual Physical
Examination: Factitious Farce or Futile Fetish," in the Medical Tribune
for March 17, 1971. In that article he calls the annual physical
examination a sacrosanct fetish with little objective evidence to show it
does any good. He backs up his argument with an extensive bibliography,
and concludes thus: "Let us resolve to be a little less susceptible to
meaningless cliches; let us recognize that a 'biochemical profile' is in
reality a series of unnecessary investigations, that I multipbasic
screening' is just a euphemism for biochemical bingo, that the 'base-line
ECG' is often a cause of cardiac neurosis, and that the 'annual physical'
is virtually a!,, -, s an annual fiasco."
In the last fifty years of periodic health examinations no statistics have
emerged showing that those who faithfully go for regular check-ups live
longer or have
healthier lives than those who shy away from doctors. They may be happier,
however. Hypochondriacs are always happier after an examination.
Prevention of illness being obviously more desirable than finding it in
its earliest stages, internists are also advocates of a variety of
prophylactic regimes. But being human and having developed in an age of
fad and fashion, they are also enthusiasts for whatever is new and of good
report. To prevent coronary artery disease, for example, they have
endorsed low cholesterol diets, no smoking, no mental or physical stress,
female sex hormones and a host of other supposed preventatives. As one
medical wag put it, the best way not to have a heart attack is to be an
impotent bookkeeper addicted to bicycle riding and a Vegetarian diet.
The low cholesterol diet was based on a logical sorites: Myocardial
infarction (the acute heart attack of the layman) is a result of coronary
thrombosis, which is a result of hardening of the arteries of the coronary
arteries that feed the heart muscle; cholesterol deposits are found in
arteriosclerotic coronary arteries; cholesterol is a major component of
ingested dietary fat; therefore, cut down on those fats and you reduce the
incidence of heart attacks. Alas! A twentyyear study just completed in
Framingham, Massachusetts, showed that there was "no discernible
association between reported diet intake and serum cholesterol level"-thus
breaking one link in the sorites-and that 11 there was no suggestion of
any relation between diet and the subsequent development of coronary heart
disease in the study group"-effectively knocking out the premise on which
so many food products are sold.
A recent rage is exercise in the form of jogging. The reasoning goes thus:
the heart is a muscle; muscles are toned up by exercise; ergo, exercise
will help the heart to function better. No proof exists for that
assumption. On the contrary, no one has data from any controlled series to
prove that life is prolonged as a result of exercise. "Whether or not the
cardiovascular effects induced by physical training will play an important
role in the prevention and treatment of coronary disease remains to be
established," says Dr. Jere H. Mitchell of the University of Texas
Southwestern Medical School at Dallas. It is also well known that members
of the laboring class die at a younger age than the idle rich and that
death from heart disease occurs more often and sooner in men than in
women. Think on that. Who gets more exercise?
Internists wear fancy headdresses and shake imposing rattles, but when
the trappings are discarded, un
The Medicine Men
derneath are only men, not representatives of divinity.
DETECTIVES
Priests they are not, but good internists outshine any fictional
detectives. They are the diagnosticians par excellence. They are not mere
technicians. They actually try to discover the cause of an illness as well
as to treat it. Sometimes all they do is think (All? Isn't that enough?)
and they come up with the right answer.
A severe anemia caused by the fish tapeworm is not uncommon among the
descendants of the Finns who settled along the shores of Lake Superior and
Lake Michigan. They enjoy a dish made of chopped raw fish. Ergo, they are
more likely to get the anemia than their fellow Americans who eat only
cooked or cured fish. But in Brooklyn the same disease occurred in adult
Jewish females (not in Jewish males) and in Jewish boys and girls under
the age of five. Guess why. Give up? In the preparation of gefilte fish, a
Jewish delicacy, the chopped raw fish is seasoned and tasted before it is
boiled. That accounts for the women, but what about the kids? Here's the
picture as described by a group of brilliant doctors: Mama is making the
fish; the children not old enough to go to school (alia! under five!) are
watching her; she tastes the fish and gives them a little to taste. I
think that's as good a bit of detection as any of Sherlock Holmes's.
Detective story number two. A man moved into a house in the suburbs on a
tree-lined street. Thereafter, almost every evening he came home with a
headache that sometimes was so severe that be bad to vomit. He attributed
the headaches to his intense dislike of his new neighbors. His doctor
elicited the surprising fact that the man had no headaches on rainy or
cloudy days. The doctor had an electroencephalogram taken; it confirmed
his intuitive diagnosis of a migrainous type of epilepsy brought on by the
flicker of the setting sun's rays through the trees. Pretty good, huh?
One more, one that has already passed into moderii folklore. A previous
healthy man began to have fainting spells unrelated to emotion or
exercise. The only significant finding in his medical history was a slow
and steady gain in weight over the preceding two years The spells came on
Sunday mornings in church but not when he didn't go to church; they never
came on Sunday afternoons. They came when be sat alongside hi,-. wife on a
wall banquette in a restaurant, but ne%c
Members of One Body
when he faced her. They also appeared when he turned his head suddenly,
the doctor discovered. The doctor did one simple pressure test and
announced, "Your shirt collars are too tight. You are getting too fat. You
have carotid syncope." That's a fainting spell induced by pressure on the
carotid sinus of the neck. All right, so you've heard that one before, but
it's true nevertheless.
Not all detectives are Ellery Queens, however. A construction worker named
Joseph Snow moved from Brooklyn to Indianapolis. He had to have a preemployment physical examination before starting a new job. The doctor
(careful, but of limited horizons) noted the peculiar bronzing of the
skin, the scanty body hai~, and the smooth unrazored face despite
normally-sized genitalia. The doctor told Siiow that he had an eddocrine
disturbance, probal3l\, in the adrenal glands, that it was retarding the
development of masculine hirsuteness, and that be should get male sex
hormone injecti(ins. Snow, the father of four children, blinked. "No
Mohawk Indians hai,-e to shave," he told the doctor. And that's a true
story too.
There's a lesson in these four tales. A good internist is a humanist. He
knows about religion as well as arrhythmias, arts and letters as well as
asthma and lead poisoning, sociology as well as sarcoidosis, men's
occupations as well as their response to oxygen therapy, and how people
live as well as what they're sick with.
"A dermatologist has the best kind of practice. He has no emergency calls.
His patients never die and they never get well."
"A pediatrician has the best patients. They're frequently ill and they
seldom die."
"People who consult a proctologist must have confidence in him. They can't
see what he is doing."
"Orthopedists don't have to worry. They always give a guarded prognosis
and on that basis can treat a patient indefinitely."
"The fear of blindness is so great that no one objects to paying the eye
doctor."
The above aphorisms, (presumably witty remarks of their professors) culled
from medical students' notebooks, are examples of how some of the other
specialists view their fields of practice. The "in" humor barely conceals
the realities. Concern for the patient is present, of course, not for his
sake alone but also for the
sake of the doctor's reputation.
The dermatologist treats chronic skin disorders. Naturally, for acute
eruptions are gone by the time the patient gets an appointment. Hives,
poison ivy dermatitis and sunburn are treated by mothers, grandmotbers,
friends and patent medicines. The American Academy of Dermatology
estimates that fewer than 30'//( of all skin problems come to the
attention of the dermatologist. Dermatologists belong to two schools: one
relies only on inspection of the skin to make a diagnosis; the other, on a
full history plus inspection. The latter may seem more rational, but the
additional information may merely add confusion when inspection of the
skin is not conclusi\,e. Example: A married woman develo~ed a peculiar
itcliiiicr eruption on her body after each time she met her paramour in a
cheap hotel; one dermatologist deiiioiistrated her case as a skin
manifestatioi-i of a guilt reaction; another looked at the rash more
closely and said, "Bedbug bites."
Regardless of the diagnostic technique and often regardless of the
diagiiosis, the dermatologist follows a standard procedure - n treatment:
stop all previously applied medications, clean the skin, use a steroid
locally for itciiiiig plus antibiotics as indicated, use tar ointments for
more chronic conditions, use peeling agents for still more chronic
troubles, have the patient return for frequent clieck-tips on his
progress.
Some skin ailments are self-limited; that is, they last a few weeks and go
away regardless of the treatment used. ForttiiiateIN, for the
dermatologist, there are few of such unrewardincy diseases. Acne is great
for him; he has willing and desperate patients made more desperate by TV
commercials and advertisements in teen-age magazines. Psoriasis is just as
good. So is athlete's foot.
The only trouble a dermatologist has is in making an impression on his
patient. If he merely looks, makes a diagnosis and prescribes, where's the
glamour that should attend a .~isit to him and the payment of a fee? The
dermatologist, therefore, must do more. He cannot don a mask nor do a
dance, but he can subject the skin to a variety of direct treatments:
carbon dioxide slush, Xrays, ultraviolet rays and so forth. (The medical
term for such techniques is modalities. Modalities is pure jargon, an
elaborate way of saying methods. Even the medical dictionaries are
shamefaced about dpfining it.) Of course, the treatments may be of
questionable worth, but dermatologists are honest men and like to give
value for the money they get. I once asked a dermatologist why he was
giving weekly ultraviolet
treatments to a patient I had sent him. His reply: "I have to see her once
a week to check on her progress. She'd be unhappy if she just walked in
and I looked at her and said, 'You're doing fine.' So a little ultraviolet
NNlon't hurt."
Ultraviolet may not, but X-ray treatment is undoubtedly dangerous. For
almost fifty years, epilation (artificial baldness induced by X-rays) was
a standard treatment for ringworm of the scalp. The procedure was
abandoned in 1958 (thirteen years after Hiroshima) not because of concern
over possible bad effects, but because a new drug, griseofulvin, was more
potent and much simpler to use. Now a study by Dr. Roy Albert of the New
York University Medical Center has shown that in the patients treated by
X-ray epilation there has been ten times as mi-ich cancer and leukemia as
in an unradiated population, and what is more surprising, three times as
much mental illness.
Don't you get the feeling that a specialist in skin diseases should not
try to do too much? Shouldn't you be willing to pay him just to hear him
say, "This condition is trivial and will require correspondingly trivial
treatment?" And never use the ointment or lotion or medication he's
prescribed without having asked him, "Are there any dangers in this
treatment?"
Most pediatricians, unlike dermatologists, have no quahns aboi-it
dismissing ailments as trivial. They take pride in being the big poohpoohers in medical practice. A pediatrician has undergone rigorous
training in the care of sick infants and children; he knows that the
delicate physiologic balance in the young is easily upset by disease,
especially by acute illnesses; be recognizes and preaches that children
are not little adults and should not be treated as such.
So what does he do? He spends 90~'c of his time cariiig for well babies
and examining healthy school children at regular intervals. Don't get me
wrong. That's not bad. But that type of preventive medicine (measuriiig
and weighing, giving aiitidiphtheria toxoid, vacciiiating) can be done by
public health nurses or by general practitioners. Why let the
pediatrician's good training get lost in so mucii banality that be has no
time to use it NN,heii it's needed? You've heard the joke: "Doctor, in\,
I)ab\, just swallowed a bottle of aspirin." "Don't wori-N-. Give him an
aspirin and bring him to the office tomorrow." NN'hen a child gets sick
outside of the normal visiting hours, the child is seen by a general
practitioner or is taken to the emergency room of a hospital. Certainly,
if be has a contagious disease like measles,
The Mediciite Me
German measles, chicken pox or a streptococcic sore throat, he doesn't
belong anyway in a doctor's office where there are well children tearing
the place apart.
To justify his existence as a specialist, the pediatrician is an educator
and ai-i indoctrinator. He teaches young mothers important things like bow
to dress baby, when to ignore baby's cries, when to start bowel and
bladder training, why pacifiers are better than thumbsticking, and when to
start solid foods. His indoctrination is of the mother. He is an expert at
instilling motber-guilt. Baby gets up too often at night? Mother doesn't
give it enough attention during the day. Baby rejects the strained
spinach? That's because mother makes a face when she spoons it 'Out and
babies are ultrasensitive to parental attitudes. Baby has no teeth at
twelve months. Mother, don't be so competitive. Baby screams when be moves
his bowels? Too much emphasis on defecation. Sometimes-often-the poor
mothers get the impression that everything they do is wrong. That's the
idea of the visits to the pediatrician. his raison d'etre. He's there to
correct her mistakes.
Not only by his airy dismissal of complaints is the pediatrician
distinguished from his medical colleagues, but also by the time-limited
nature of his practice. His patients can last only from birth to
rebellion, when the% leave him for other medicine men. He must, therefore,
run constantly in order to stay in the same place financially. He must
attract to himself new patients via their mothers. He must make himself
remarkable over his fellow pediatricians.
That he does by being an innovator. He adds cereal to the infant's diet
when the infant is six weeks old. His competitor raises him by adding it
at four weeks. He counters by adding it at two weeks. He introduces the
hapless child to strained spinach a week earlier than was customary, and
another pediatrician answers by starting yogurt even earlier. One man
"hardens" his infant patients by cotinseling against the wearing of hats:
another puts the baby outside clad only in diapers. One encourages
crawling; another advocates baby-walkernOne advises small toys because
they're easy to gras thus hastening small-muscle control; another
,,.,ariagainst them because they may be swallowed. Oi pushes for cuddly
plush animal toys; 4another tak them away I)ecatise they're allergenic
dust collectors.
Divided as they are in their techniques, pedi~icians present a united front against parents. Pe(li.t*-' ~ k.
cians (childless ones not excluded) say the,% k--what's best for the
child. Doing what comes natural". for the birds, not humaiis. And so,
within the nier--..
Members of One Body
of man, the I)endultim has s,,N-iiiig from rigidit~, in feeding schedules
to permissivei-jess and back again, from bare feet to corrective shoes,
from enforced naps for greater vitality to delayed b(~(Itime for more
socialization.
NleanNN,Iiil(~, lost in the (,oiiipetiti\,e strti,,gle tiid overwhelmed by
the authoritarian approach is the poor child, supposedly the subject of
tender i-iiiiiistratioiis.
The proctologist's field of actin-itv is N,er,,, Iiii-lited, but he's very
busy there, iienertlieless. Aiial ,N,orries left over from childhood,
stipple in eii tcd 1)-,7 a sti-oii,, caiiipaigii against cancer, send
titoiisaiids of patients e\-(,rN, year to proctologists. The
,N,illiii,,iies.s of the pi-octologist to mess tround in tliitt usually
filthy area (I)ecatise not all patients wasli tlieiiis(~l\,es before going
to the doctor) gains him the de\,otioii of his patient, ,,,Iio will
sul:)mit to the passage of pi-octoscol)e and si(,,ii-ioi(loscope without
deii-itit- and ,~,ithotit poiideriii(y on the fate of EdNN,ard 11.
(Perhaps ~ipoeryphal. The poor king was supposed to have been done in by
the passage of a hot iron bar up his rectum. The sigmoidoscope is liollow
and shiny but probably of the same dimension as the bar.) The patient
wants to be told be doesi-i't have cancer; the campaign literature says
that no physical examination is complete without a proctosigmoidoscol)N,.
And now I quote: "It is not popular . . . to do anything to thwart the
efforts of the cancer society (i ' rotips that make a career of
instilliiig in all of us the fear of a horrible cancer death . . . The
fact is that none of the reported series of large-scale routine
sigmoidoseopic surveys of apparently healthy people has turned tip very
much information that could be used to help the patient."" Ftirthei- data:
A series of 1000 consecutive patients at the Lahey Clini(, on whom
sigmoidoscopy was done was evaluated.12 Of them, 637 had minor rectal
conditions, most of which benefited from ad-,,ice ,11)oiit diet, local
bygiede, Lnd medication. Only six c,iiic,ers \N-ei-e found, and in every
one of these the patiezit~, li,i(I complaints of rectal bleeding. In a
1966 stirveN at the NfaN-o Clinic in ,t series of 1000 sigiiioi(10scopies
on p.itieiits ,Nitbout symptoms, not one cancer was foundI get the distinct impression that a patient would do better to turn his
thoti(-,Iits aN~-ax, from his fundament tip to the spacious firmament oi,
liigli.
There is no need to co into (letail al)otit the other specialties. NVhat
goes for oi-,e goes for all. The doctors trip their magic round, bcmtise
their patients and
tlieiiiselxres, and push aside the nagging ,iiats of doubt. The patients NN~atcli the wondrous dance, applaud the priests and cry for more. Two ii-take a team-doctor and patient. One skeptic on either side (lestron-s
illusion. But perhaps illusion is more comfortable than reality. Oi)e
thin(, is stii,e-it's not healthier.
13.
FRAGNIENTATION
A forty-year-old ,N-onian trying to recapture her youth began to -,N-eai\-erN7 short skirts. She noticed that liei- ri(flit tliigli was qtiite a
])it sniallei- than her left. She went to an orthopedist, \N-lio measured
both tliiglis and found she was correct. The circtimfereiice of the left
tlii,,,Ii was three inches more than that of the right.
The orthopedist put liei- tlii-otit,li a series of exercises. He found
that there ,N-as no muscle or joint weakness. The woman could stand ~iiicl
NN,alk \i,,itliotit trouble. He was puzzled by what lic~ considered an
atropli,,, of the right tliigli. He sent the \),,oiiiaii into the hospital
for a thorough clieck-tip.
The iiiterii took- a complete historv and did a pli),~sical
(,xadiiiiatioii on the \N-oniaii Ivin,, in bed. Because ati-ol)li,,7 of
the tlii,,Ii iiia\, have resulted from a iietirologic, disorder iiid
because he was going to be an ophthalmologist, the iiit(~i-ii paid
particular attention to the enle grounds, a \,altiable iiidic~itor in
multiple sclerosis, brain ttimors and related disorders. The e,,-e grotiiids were normal.
The residei)t went over the iiit(,i-ii's Iiistor-,- and physical. Because
lie planned to be a ,\iiecolo,-~ist, the resident did a careful vaginal
exaiiiiii,itioii ~iiid found nothing of moment. He made a note oi) the
chart to that effect and ordered a laboratoi-\- \N-oi-k-tip.
After $450 worth of lal)oratoi-,,- tests ( that cost the hospital less
than $50 to do) came I)acl, negative, a neurologist examined the patient
it) consultation. He found no iier\,e disorder that \N-otilct account for
the right thigh being smaller than the left.
After the tests were finished \N-itli and while the doctors were making
tip their iiiiii(is NN'liat the diagnosis was, they ordered pliNsiotlierap~- to be given to the
11 Dr. Eddy D. Paliiier, "Diagnostic Endoseopy," Ciirrent Afedic(il
Dige~t, .'\larch, 1968.
t', Reported in Cti-A Cancer Joiiriial for Cli?iician~, Niarch, 1968.
-13 Drs. C. Q. Ntoertel et al., iii Ifayo Clittic Proceeding,~, 41:368,
1966.
48
thigh (heat, massage, muscle stimulation). The physiotherapist by error
started massaging the left thigh while the patient lay on her abdomen.
"What's this?' she asked. "What's what?" asked the patient. "You're on the
wrong side." The physiotherapist made a note on the chart: "Ltimp at back
of left thigh."
The attending doctor read the note and went over the left thigh. He found
a flat fatty tumor, apparently under the posterior muscle of the left
thigh. It was an ordinary lipoma, a benign growth that Deeded no treatment
except for cosmetic reasons.
The doctors all realized that the right thigh had nothing wrong with it.
The difference in circumference from the left was due to the presence of
the tumor on the left.
14.
"Grammarian, orator, geometrician, painter, g,,.,innastics teacher,
fortune teller, rope dancer, phn-siciaii, conjuror-he knows everything."
itivenal, Satire, III
And now we arrive at the great nonspecialist, at the family doctor, or the
general practitioner, as -,,,on may call him. He's not happy with either
name. (He's happy with his fees, though. Recently surveys show that the
general practitioner is right up there at the top of the moneymakers.
Probably because of Ns rarity, like chinchilla and uranium, he commands a
high price. In a late issue of an advertising service for physicians,
general practitioners are being sought at a starting minimum of $25,000 to
$35,000 a year.) In a desperate attempt to build up his own ego the family
doctor has begun to call himself a generalist vis-~-vis the specialist. He
seems to think that the name gives him a cachet, that it implies that be
knows everything about everything in medicine, that he is really the
captain of the ship, with the specialists subordinate to him.
Giving himself that name plus a little political pressure properly
applied in some hospitals has led to the setting up of divisions of
general practice in those hospitals. Theoretically, then, the family
doctor is on a par with the surgeons, the internists, the pediatricians
and all the o * ther specialists. Actually, he finds that for the most
part he is not allowed to do operations more complicated than
circumcisions or the removal of an ingrown toenail nor permitted to read
electrocardiograms nor treat a child in convulsions. If a patient is sick
enough to be hospitalized, the reasoning goes, he's sick enough to require
the services of a specialist.
When it comes to knowing everything about every
The Medicine Me
thing, alas, too often the general practitioner knows too little about not
much. He's kept busy taking care of the everyday illnesses of the flesh,
like tonsillitis, acute bronchitis, bellyaches and diarrhea, not to
mention migraine, inflamed eyes, Dervous indigestion and infected
scratches. He works very hard all day and many nights giving the medical
care that specialists feel it is beneath their dignity to provide. He has
little time to wade through the self-servidg puff articles in the medical
journals so that he can separate the rare nugget of information from the
dross. It follows then that he goes on doing what he was taught in medical
school with the addition of what be gleans from an occasional lecture or
the mountains of pharmaceutical company advertising matter that come in
every, mail. He has a smattering, it is true, of every branch of medicine,
but that smattering is spread thinner than a blood smear on a microscope
slide.
The situation is not entirely due to the general practitioner's stick-inthe-mud attitude. It is perpetuatedindeed, the process of deterioration is
accelerated-byl the edtication doctors get, particularly in the clinical
aspects and in the internship. How can you expect them to learn when
residents (one notch higher on th totem pole) take care of all the minor
and much majo surgery, do the deliveries and tend the very sic medical
cases? About all the interii who's going to be general practitioner can do
is look on, take orders an run errands. Some general practitioners
complain tha they never get a chance to utilize the skills for whic they
were trained; more likely, they were never traine for the skills tlie~,
need.
They are conscious of their incompetence. (That's harsh word. But wliei-i
the doctor gets sick, does he g to a fellow general practitioner or to a
specialist? Wh do you think?) They also resent their medicosociall
inferior position. Family doctors, therefore, have song out various
approaches for restoring their status i the hierarchy and for improving
their image in the pti lic eye, to use Madison Avenue lingo. First they
form an Academy of General Practice, membership in wlii required a
definite number of hours spent in attendi lectures, conventions and
classes. A good idea, fall amongst vacationers on cruise ships, at Las
Vegas a on combined golf -and-learning trips. All one bad to was register
to denote attendance, after which cr('~', could be claimed, and then the
tired doctor colil(i fresh himself in more entertaining surroundings til.-. sleep-inducing darkened lecture hall. That metli(~,,; self-improvement
and stattisseeking having sliox% Members of One Body
self to be innocuous and equally meaningless, other proposals were made.
One group wanted family doctors to have freqi-iently repeated examinations
to make sure that they're up to date in their diagnostic and therapei-itic
techniques. Nlost of tl-ie gei-teral practitioi-iers were in violent
opposition to that suggestion. They ol)jected, not without merit, to being
singled out to take such examinations when specialists don't 1-iave to.
Another group wanted to create a specialty board so that general
practitioners would be able to call themselves specialists. Naturally, the
specialists were against st-ich a board because it would dillite the
N,alue of their own boards. Some fan-tiln, doctors, too, were i-iot
wholeheartedly in favor of it because, in a rare burst of lioiiesty, they
recognized that iianiiiig, like thinkii)g, would not change reality.
A specialty board for faii-iil-,- physicians was fiiia]INIcreated,
however. Are the general practitioners happ~, now'? Not so you could
notice it. Some of them see further restrictions on them in the offiiig.
Tlie,N- fear that the boiia fide specialists will say, "Yours is a
iioiisurgical board. Good. No surgery for you," and then the G.P. will
have en,eii fewer hospital privileges than lie has now. Othei-$ , xn,ai-n
that the board will discourage medical students from troiii(r into ,eiieial practice because of the periodic recertification requirement, ,N,Iiicli
is not required in the other specialties. A cn,nical feNNapplaud the board
because iionv 11 specialist" ,eiiei-a] practitioners will be able to
charge more for tbeii- sei-\~ices. Discontent is N,ocal: only 201-e' of
California's (-reiieral practitioners said tliev would consider takiii,,
the board examinations.
Still another group, ,N,itli much support from medical schools, medical
reforiiiei-s and iiiedical philosophers, igi-iores the board entirely.
That group says that general I)i-actitioiiers should be transformed into
I)i-iiiiai-,il ))Iitl
Their function NN-ill be to DI~ike the first teiitati\-e to treat all
trivial ailments, to direct ii-ioi-e
to the proper specialists, to co-ordiiiate the ()f the specialists and to
supervise treatilielit I', , 'i~(, tli~it they will be alerted to untoward
effec.tn. III \%()I-CIs, the primary physiciai-i will act
like a sortiiit_l ()i, Li I)attle aid station, separating the gra\-el\
hurt fr,),,ii ~\al~-iiig wounded.
The faiiiil\- tli~it then they'll be merely
the eqtii\-aleiit of hospital corpsmen or
Europeaii-t~'pe Feltiiit,r\.
(loii't \N,aiit to accept a
permanently iiiferior \N-liat faiic,,, name
it's given. Tlie~,l eii]int tilt- I)lil)ll(- oii their side. They object
that such a s\-stt.~iii \%ill (It~I)ri\e patients of the
49
compassion and human sympathy doctors are noted for in soiig and story,
and often in real life.
That wziri-i-i interpersonal relationship is supposed to have a gi-eat
therapeutic effect in the liealiiig process. Yoti'\,,e heard people say,
"Nly doctor absolutely insists that I . . ." and "Nlv doctor strictly
forbids me to . . ." and "i'\Iy doctor -,N,~is pleased that I . . ." You
can just see the doctor I)eamiii,, and citick-eltickiiig.
Tender I.o\,iii(, C~ti-e. Tlztit's the real specialty of the faii-iilv
doctor. Ile is the coiisolei-, the adviser, the lay fatliei--coiifessoi-,
the I)riii(,er of hope, the shoulderpatter. His art ti~iiisfoi-iiis cold
science into wariii tinderstaiidiii(,,. He stztiicis, a fearless knight in
rtimpled clothes, between the -kii(,cl of Death and the frightened family.
A glowiii(r pic-tiit-(,. )'oti'\c, seen it in the iiio\,ies; ~,oti I \Te
read about it in the iio\els. (1,-,\-eii the scurrilous aiitidoctoi- iio\cls ()ii(~ iiatiii-e's nobleman arrayed ~t,gaiiist the licentiousness
aii(I of ]]is coiifi-ei-es.) \-oti think N-oiir o\~lli (loctoi- is like
that. I hope lie isn't. 1'eii(Icr Lox-iii(, Care is no stibstittite for
coiiiiiioii s(~ii,,(,: can't take the place of aiitil)ioties~ ~iii(Iii(~ss iii~tx~ he a cover foi- i(,iioraiice. NN'liat ),on need is ~t
cloc~toi- \N-lio kiio\N,s \,%,hat lie is doiii(r ztiid wli-,,. If his
I)c(l.sicle iii~iiiiier is sootliiii(y, if his pres(,iice spreads
coiiifoi-t. so much the better. That's la(,,iiiappe, I)tit the pi-iiiie
consideration is the applicatioii of a scientific attitude to\N-ai-cl the
(li~i(,iiosis and treatment of (lise~ise. Otlici-\x,ise the cloc,toicould dispeiise xn,itli his stethoscope and piesci-il)tioii pa(l: lie
could (loi-i a biretta and s\viii(i a ceiisei,.
Popular nia(,aziiie \N-riters bewail the 1)~L,,siii(, of the old-stn,le
faiiiil\, (loctoi-. They advise tli(,ii- to ti-\,
lwty to establish a iiieaiiiii(,ftil i-el~itioiisliip \N,itli a personal
physician. Doctors iio(I ~ipl)i-()\,il of such fosteriiig of iiostal(,ia
for the "good old (1~i\-s." NN'llat's looked for is rapidlv I)ecoiiiiii(,
~t Iii,,,toi-ic-~il curiosity, A (Tood thin(,, too, that it is. The
I)tiiiil)liii(, but syii-ipatlietic doctor, so I)tisv I)a\-iii(, tli(, io~i(I to liell with his inteiitioiis, I)eloiigs in a iiitisetiiii, not Lit
a patient's I)e(lside.
Dr. LaSagiia sa\,s in Life. Death, (iii(I the Doctor,
"The i-i-iaii whose life is tlii-e~tteiie(I ])\~ a coiiiplic~tteci it]
fectioii . . . demands technical expertness, fi-odi a misaiitlirope, if
need I)e." Then the doctor lied(les with, "But there still i-eiii~iii)s
~iii enormous range of human illiiess ... where 'iiia(,ic I)tillets' are
lackiiig" and mantial skill or special ti-aiiiiii(ly is not needed, and
for these ailments the doctor must dispense the milk of human kindness. I
Ltsk \,ott-~.N-Iiy the doctor? NVhv not '\lama?
50
Or Madame Zodiac, the spiritualist? Or the bartender?
from hemorrhage from his ruptured spleen right at the
door of the emergency room. They never forgot how he stayed all night with
the Hammer woman in her labor, bustling around the kitchen, telling the
three little children funny stories to keep their attention away from the
shrieks from the bedroom, giving the suffering woman needle after needle
to ease her pain, and thei-i having the miserable job of delivering a dead
baby by high forceps. In the four terrible days of delirium before Mrs.
Hammer died of sepsis, be was with her day and night, standing by her
bedside, adjusting the tube that slowly dripped the serum into her veins.
People iie,,-er tired of telling how Old Doe broke down and N,.,ept the
iiight Mrs. Hammer was laid out and how Mr. Hammer had to drive him home.
Old Doc had a social conscience too. He gave lecttii-es to the Boy Scouts
on what they should know about health and hygiene, explaining to them the
horril)le consequences of masturbation and evil living. He NN-as a
generous contributor of cash to the Dorcas Home for Unwed Mothers, besides
giving his services gratis and sboutiiig at those patients who cried out
during labor so that the girls would learn a lesson they'd never forget.
He was a vigorous advocate of compulsory immunizations and other
preventive health measures such as tonsillectomy. He was not a stickin-
the-mud. He gave birth control information to married women. He treated
venereal diseases by the latest methods, making sure that his nurse
immediately phoned in the name of the patient to the Board of Health as
required by law, from hemorrhage from his ruptured spleen right at the
door of the emergency room. They never forgot how he stayed all night with
the Hammer woman in her labor, bustling around the kitchen, telling the
three little children funny stories to keep their attention away from the
shrieks from the bedroom, giving the suffering woman needle after needle
to ease her pain, and then having the miserable job of delivering a dead
baby by high forceps. In the four terrible days of delirium before Mrs.
Hammer died of sepsis, he was with her day and night, standing by her
bedside, adjusting the tube that slowly dripped the serum into her veins.
People never tired of telling how Old Doe broke down and wept the night
Mrs. Hammer was laid out and how Mr. Hammer had to drive him home.
Old Doc had a social conscience too. He gave lectures to the Boy Scouts
on what they should know about health and hygiene, explaining to them the
horrible consequences of masturbation and evil living. He
The Medicine Men
was a generous contributor of cash to the Dorcas Home for Unwed Mothers,
besides giving his services gratis and shouting at those patients who
cried out during labor so that the girls would learn a lesson they'd never
forget. He was a vigorous advocate of compulsory immunizations and other
preventive health measures such as tonsillectomy. He was not a stick-inthe-mud. He gave birth control information to married women. He treated
venereal diseases by the latest methods, making sure that his nurse
immediately phoned in the name of the patient to the Board of Health as
required by law, except when he knew the patient well. Then he used his
judgment and ignored the law.
Young and old alike adored the Doc. "When you come in the door, I'm
halfway better already," was a common remark. His colleagues in the Lenape
County Medical Society held him up to incoming physicians as a shining
example of what a real doctor should be.
The Old Doc began to have pains in his stomach and lost much weight. He
went to the Medical Center fifty miles away. The doctors there marveled at
the constant stream of flowers and getwell cards that poured into his
room. "If we had more men like him," growled the professor of surgery,
"there'd be none of this nonsensical talk about socialized medicine."
Old Doc never came back from the ),Iedical Center. His cancer was too far
gone. His funeral was magnificent.
A young whippersnapper took over his practice, to the dissatisfaction of
the townspeople. They missed Old Doc. Mrs. Smith, wbo'd been bedridden for
a year with "kidney dropsy," grudgingly admitted when she began going back
to church and eboir meetings that the new doctor's treatment was good, but
he just didn't have the touch Old Doe had. Mr. Jones, whose "chronic
rheumatism" disappeared on the diet and tablets the new man gave him for
his gout, complained that he now had no chance for gabbing with the doctor
about state politics. Miss Robinson, the schoolteacher, no longer looked
forward to the badinage of the Saturday afternoons when she used to get
her weekly liver shots for anemia; the new fellow removed her cervical
polyp and the bleeding stopped.
Old Doc's memory lingers on. Five years after his death, the Baby Health
Station was named after him in gratitude for his long and arduous service
to the people of the town.
MORAL: The milk of human kindness may not be as effective as the proper
medicine for an illness, but it tastes better.
51
The Powwow
"Two great physicians first My loving husband tried
To ease my paiii-iii N~aiii. At last he got a third
And then I died." Epitaph in Cheltenham clitii-cliN-ai-(l
The consultation, a convocation of medicine men, takes place when the
patient's family has doubts. They worry that their own ai-igtir may have
misinterpreted the omens. They worry that his brew lacks potency. They
decide that their own death-wishes ("I wish Mama would get better or
something") must be overcome by multiplication of magic. Two beads are
better than one, they figure, even as shrunken ornaments.
Doctors are well aware of how families feel. The patient is a secondary
consideration. The families pay the bills. If the patient dies, the family
must have no regrets that they have not done enough. If he lives, they
must be able to congratulate themselves on their foresight in having a
consultation. So virtue is made out of necessity. "In the interest of the
patient" consultations are called. No families object. They are pleased
that their doctor (in whom they say they have the greatest confidence) is
asking anotl-ier doctor to give his opinion. They have two levels of
thinking: on one they know that two doctors seldom disagree and that
whatever changes in regimen will be made will be done solely to justify
the consultation fee. On the other they klio%\- that a doctor one hundred
pei- cent sure of him
!f %%-oiild never think of asking another doctor to see
T ~o -:iiiiiier in which consultations are conducted lm clia.-, --, (I oner the years. It used to be that the doctor in %koiil(l tell the family
that he wanted a coiistiltatio:-, If(- %%-oiild then call his consultant,
meet him at the ()f the patient and send the familv outside the rOOTli
Tli(~ c,)iistiltaiit would listen to the doctor's recotilltiT)Z of tlit,
1)atieiit's history and then would examine the patit,rit. -kfter\~-ards,
both doctors would go into a huddle fir front family or patient, in
another room if possible, or at least iii the I)athroom. Both doctors
would then meet the fri,,Iiteiied family. The attending doctor would state
the consultant's opin-
ioii while the lattei- iio(l(iecl in al(ri-eciiieiit. The feNN, questions
fi-oiii the f'ztiiiiln- \Noti](I I)e (leftl,,- ~iiisNN,ei-eci ii) doubletalk, lea\-iii,-, tileiii c-()iifiis(,(]. The coiistilt~ijit would accept
his fee ~iii(I (1(,I)zii-t. Tlieii the faiiiiIN, would ask the
atteii(iii)(-r (loctoi-, "\N-liat (ii(i lie saN~'-)" aitcl listen to the
iiitei-pi-t~t~ttioii of the oi-~ictilai- opii)ioii.
That's cliaii(,cci iio\N-. The patient sick- ciioti(,I) to iiee(i a
consultant is iistiill\- iii ~t liospit~il. The ~itteii(Iiii(, doctor,
alert to the iiiixi(,ties of the kinfolk, tells them that he is liax~iii(,
a coiisiilt~itioii. The coiistiltztiit c~oiiies iiiiannounced aii(I
iiiiatteii(led, reads the hospital cliart, examines the I)ziti(,iit aii(i
xn,i-ites his opiiiioii on the cliart. That ol)iiiioii is tiieii retailed
to the faiiiiln- I)N ~the doctor iii c-li~ti-(,e, \\-Iici)eN-er lie
~,,,ets around to it, Preseiit-(Ia,,- pi-oc,ecitire is less foriii~il
tliiii pi-c\-iotisl,,, but just as effecti\ c. The amenities are ol)sci-\
(,(I.
NN'hen are coiistiltatioiis called? The .1()iiit ('()iiiiiiitt(~e
on Hospital Acci-c,(Iitatioii reqtiii-es tli(,iii
(',IC
sareaii sectioii is to be doi)e for the fii~,,t tiiii(~, \\Iieii a
therapeutic abortion is advised ~iii(I ()I)c,i-~itioiis
designed to cause sterility (iiiltle ()i- Lti-c coii
templated. In addition, coiistilt~itioii,, ti(, i-c(ltlii-ecl when the
patient is not a ,oocl tlii~, plii-~ise is explained latei- on), wlieii
the i-,, ol)sciii-e and when doubt exists as to the 1)(,st ti-(,~itiiieiit
to be titilized.
It is ratioiial to require a coiistiltitioii \N,-Iieii a woman is to be
subjected to the (laii(~c,i-s of it (,~iesai-eaii sectioil, for the
operation is daii,,ei-oiis, ~is the statistics slio\~,~. Butwlio's the
coiistiltziiit iii such c~ises? Usti~tll,,~ the obstetrician who is
(,oiii(, to do, oiassist at, the operation, or one \vlio \N-ill expect art
equal favor when iie needs a consultation foi- tl)e siiiiie purpose. Is it
not too much to expect of iiioi-t~il iii~iii that the\, will not stretch
the indications foi- the operation, which pavs ii-tore than another tvpe
of cleli\-er,,-" Especiallv if t~ie patient is wealtliy-else how account
for the number of Cae
52
sareans done on the wives of tycoons? They surely cannot all have
contracted pelves, high breech positions or uterine inertia.
Consultation is necessary when the attending physician NN,aiits to do a
therapeutic abortion. It is necessary for the doctor's protection against
the powers of the state, against possible charges of malpractice and
agaii)st his liecoming known as a too-willing complier with the NN,islies
of the women wanting to get rid of their iiiixn,elcome passengers.
Therapeutic abortion is a borderline euphemism. Therapeutic for whom? It
can't be for the fetus in utero. It can be only for the pbysical or mental
health of the mother, when the contii-iuatioii of the pregnancy is likely
to harm her. In other ),%-oi-ds, her health in potentia, non in esse.
Doctors in such cases do not hesitate to don the mantle of the prophet.
For the record, I am not a Roman Catholic.
(The liberalized abortion laws in some states are too iie%%- for comment.
As yet there are no complete statistics on morbidity or mortality.)
The reason for consultation in sterilization proce(lures varies. In some
states it is contrary to public polic%- except on strong medical
indications. In all it is absolutely necessary lest the tinsterilized
spouse sue the doctor for an unwarranted attack on his or her right to
have a family.
"The interest of the patient" is presumably the rationale for mandatory
consultation in the vast majority of cases. A consultation is required
"when the patient is not a good risk," or as one hospital I know of put
it, 11 when there is a possibility that the patient may die." That last
sentence gives one pause. Until men learn to read the future, who can
foretell the date, the hour and the maiiner of death? "Not a good risk"
means that the patient is very old, very sick or both. Here the
consultation is mostly to prevent suits for malpractice or to satisfy the
family. It is in the nature of calling the pi-iest, with less likelihood
of advantage from the secular sacrament.
The other reasons for consultation seem more justifi~tl)le. NN'lieii the
diagnosis is obscure or when the type of tre~itiiieiit is in question,
certainly another doctor should I)e called in to help the attending doctor
make tip his mind. The consultant, no matter how elevated his position,
I)ears in mind that all doctors are equal, except that lie is a bit more
equal than the one who called Iiiii-i in for an opinion. He is tactful,
and careful about his reputation. His tact arises out of his fear of
offending the referring doctor, thus drying up a source of income. He
gives his opinion, hedging it about with
The Medicine Men
a dozen qualifications so that he is covered in case of any untoward event
such as a quick recovery or sudden death. The family, informed secondhand
about the results of the consultation, can be pleased only that in this
case the doctors do not disagree.
How is a consultant chosen? The same way a barber or a hairdresser is.
Becai-ise the referring doctor likes him, because be is of the same ethnic
group, because his office is in the same building, because be's a good
golf partner, because be reciprocates by sending patients to the referrer.
Of course, he has to be competent, more or less. Who would go to a barber
who used dull scissors? But given the sharpness of the scissors, any of
the above becomes the prime desideratum. Somewhere along the line "the
interest of the patient" has become lost.
Not that it actually makes much difference. If it did, the great and rich
of this world would never leave it. Think of the number of physicians in
attendance on the late Pope John, oi-i Winston Churchill, on Humphrey
Bogart, on Stalin. (Stalin was suspicious of doctors, especially of Jewish
doctors. He died of a cerebral bemorrbage, possibly the victim of his own
lack of faith. None of the physicians in attendance dared to treat him
lest he survive and they be accused of plotting against the state.) By
taking thought the consulting doctors added neither cubits to their
stature nor years to their patients' lives.
The consultation, a necessary evil, looks for the most part like a
magnification of the mummery that goes with the practice of medicine.
53
In the Medical Staff Lounge
"Two heads are better than one-except on a calf."
Folk san,iiig
"I saw that fellow in 308 for you. I put a note on his chart. Do you think
Allied Chemical will go up any more?"
"The woman in 419 is going out fast. Better get an ECG for the record. To
cover yourself."
"Try ampicillin if tetracycline doesn't work. Are you going to Henry's
party this Saturday?"
"In that case, advise the operation. If there's any doubt in their minds,
call me and I'll coi-ifirm your opinion."
"He's i-iiiiety-sex-eii -,-ears old and in iii-eiiiie coiiia for the past
three da-,-s. Drop iii and take a look at him foime, will you?"
"Nfetastases all o\-ei- the I)ocly, fltiid ii) tli(, cliest, down to 80
potiiids from 1-,0, and the faiiiil\- xn-aiits a consultation. So
coiistilt, please."
"Rule out infection. Get a culture. Yoti can tell his wife we acreecl on
it."
"NN"-Iio's lie" I iie\-ei- saw him before. Does be li~, hospital
privileges here? Who called him iii coiisultation?"
The Bubbling Cauldron
"I firmly believe that if the whole nwteria 'medica
could be sunk to the bottom of the sea it would be all the better for
mankind and all the worse for the fishes." Oliver Wendell Holmes, Harvard
Medical School Lecture
Not eye of newt, nor toe of frog, not even powered unicorn's horn nor
mandrake root goes into the remedies doctors prescribe. Past is the era of
nauseating mixtures when the worse.the medicine tasted the more hialil~,
it was regarded. Pills now come in variegated li ties, capsules in all the
colors of the rainbow, and the liquids are fruit-flavored. Drugs are
prescribed on a ratioiial basis, no longer because they fit the phases of
the iiioon or follow the traditions of the fathers.
It was not always so. Following the rise of scientific pharmacology and
the discovery that most of the medications doctors were ordering were
worthless for cure, came a period of therapeutic nihilism. Physicians
still wrote prescriptions, it is true, but they were conscious of bow
little they helped the patient. The dialectic spiral continued; as
chemistry progressed and animal and human experiment went on and more
information was gathered, some old remedies regained their place and new
ones were added to the list of useful drugs
Starting with the arsphenamines and the later sulfonamides, medicine
entered the modern age of wonder drugs. Antibiotics, psychotropics, blood
derivatives, anticancer drugs-every year sees more and more novel
additions to the inventory of weapons the doctor uses in his fight against
disease.
And every year sees more and more novel iatrogenic
disorders brought on by those very weapons. (Iatro
,,eiiie comes from the Greek: iatros =physician and geiio3 - cause; hence,
iatrogenic = caused by physicians. This is a new word, not found in
dictionaries published prior to 1953. ' In 19D'4 Stedman's Medical
Dictionary defined it as meaning "caused by a physician's injudicious
statement," indicating that the disease was all in the patient's bead. By
1961 the current broader meaning, "caused by physicians in the course of
treatment" was well established. ) latrogenic disorders have reached
the point where a prominent physician sadly says, 100, 1964.
The Medicine Men
"Unfortunately iatrogenic disease can now take its place almost as an
equal alongside the bacteria as an impor
"44
tant factor in the pathogenesis of human illness.
Another physician seriously recommended that departments of iatrogenic
medicine be introduced into medical schools.
The drugs are not harmful in the sense that poisons like cyanide are. By
no means. They accomplish what they're supposed to do-kill bacteria,
prevent infection, suppress inflammation. But they do a little more
because of their very potency and their effect on the total body organism.
Bark tea and ground-up goats' testicles didn't do much of anything, but
they didn't make the patient sicker, either.
Everyone knows about thalidomide, so let's forget
that one. But let's not forget that pregnant women still ask for and take
antihistamines for colds, antiemetics for nausea, and dozens of other
medications prescribed during their pregnancies. "When will they ever
learn?" Or their doctors. I know doctors who prescribe pbenothiazines of
various types for anxious or emotionally upset mothers-to-be; yet the
manufacturers of those
drugs warn that "the use of
is not recommended
during pregnancy," and one tranquilizer (haloperidol) has been shown to be
the cause of gross deformities in the newborn infant. A drug used for
dizziness definitely causes monstrosities. Two drugs widely used in
bladder and kidney infections are marke~d""contraindicated in pregnancy";
nevertheless, the~ are 'Used during that time. I made an informal survey.
I asked eight doctors
44 Dr. David M. Spain, Complications of Medical Practice, New York, 1963.
See also: Dr. David P. Baer, "Hazards of Modem Diagnosis and Treatment-ne
Price We Pay," Journal of the American Medical Association, 159:1452,
1955, and Dr. Elihu M. Schimmel, "Ile Hazards of Hospitalization," Annals
of Internal Medicine, 60:
Cauldron
whether they would use these two drugs during pregnancy. They were all
surprised at my question. "Why not?" they asked. A very commonly used
analgesic bears the warning: "The safe use of - during pregnancy has not
been established." In my same survey my informants laughed at me when I
asked whether they used -. "What's the matter with you? Are you some kind
ofkalph Nader nut?"
Let's start with the tried and true-penicillin and the other antibiotics,
the "use of which has been one of the major tberapeuti'c advances of our
time. (Antibiotic means, as you know, against life-by common consent, the
lower forms of life. It is not meant to apply to humans.) Pneumonia has
lost its terrors, subacute bacterial endocarditis (fatal when I went to
school) has been conquered, septicemia (the blood-poisoning of folklore)
is a rarity-all due to the naturally occurring and synthetically produced
substances known as antibiotics. Other troubles have taken their place:
severe asthma, violent skin reactions, an occasional death occurring when
penicillin is given by mouth or injection in some individuals. To use
pencillin routinely in the treatment of colds and other self-limited
diseases is to kill a fly with a sledgehammer, or rather, to swing at the
fly, because penicillin is seldom, if ever, of value in such conditions.
What's accomplished is the sensitization of the hapless patient; he may
become allergic to penicillin and then must be as careful to avoid it as
the hay fever sufferer is careful not to pick ragweed. Unfortunately,
penicillin is given to cattle, too, for their infections; it may be
excreted in milk or stay in the tissues, so that a penicillin-sensitive
individual may get allergic rhinitis or bronchitis or hives when he eats
meat or drinks milk.
Another effect of penicillin and the other antibiotics is directly
related to their effectiveness as destroyers of
~c~teria. What is known as overgrowth takes place. All
.),icteria, noxious and innocent, having been de the fungi normally
present in and on the body
,,Dm spreading by biologic competition with tiw ire able to flourish
luxuriantly. Monilial infect3:.)~l -" ' -- the infantile thrush of
preceding generatww E" nie so common that some pharmacombined their
antibacterials %-ith an -t-Tit specific for the Monilia fungus. Othn i,S:
-,. e,-,!:row, but as yet no fungicide
safe for mgt!sz~ ').een developed to control them. The bacfttu.' &x-a
present in the intestinal tract can be so drastxall%- reduced by
antibiotics that
their ben&ml rrla%, be lost. Diarrhea is not un
common when antibiotics are given.
One of the most feared complications, a variant of overgrowth, is the
development of infection by organisms resistant to the antibiotics.
Stap4ylococci, particularly, are the most likely,to develop~sticli
resistance. Epidemics of stapbyloccal infection became a menace to
surgical patients until semisyiitbetic peiiicilliiis effective against
such germs were developed. That period of security lasted only a few
years. Cases of resistance to the new metliicilliiis are already being
reported. 15 Now the biochemists will lia\,e to make another antibiotic to
overcome the resistaiit staphylococci.
Warnings against the iiidiscrimiiiate use of antibiotics seem to have
little effect oii doctors, especially the surgeons. The latter give
aiitil)iotics prophylactically; that is, they prescribe tiieni for postoperative use to prevent wotind infectioiis. For exaniple, 38~~ of
patients were given aiitil)iotics I)ropli,,- I act icalln, after repair of
simple ingiiiiial lieriiias. I quote: "Sitice iiiguinal herniorraphy is
one operatioii in x-.,Iiicli iiifectioii should not occur if proper
selectioii aiid prepar~itioii of patients are observed, aii(I if adequate
stirgical aseptic technique is folloNN-ed, then this uiinecessarn,
prophylactic use is illogical, unscientific, and contrary to the welfare
of the patient.""' Survey after survey has shown that prophyleatic
aiitil3iotics have not concltisin,,ely reduced the incideiice of postoperati\re infections, but they are still widel,,, used despite the danger
that the practice will fa\-or and select orgaiiisnis resistaiit to the
antibiotics. 17
Besides the general effects of the antibiotics, harmful changes occur when
specific ones ~,re used. Cliloi-aniphenicol is a highly efficient
bacteria] a(Teiit; it controls the growth of bacteria by iiihibitiii(y
protein synthesis in them. It can do the same in litiniaiis-aiid result in
a profound and fatal aplastic aiicii)ia. Testiiiioii\, at the hearings of
the subcommittee headed I)%- Senator Gaylord Nelson disclosed that about
150 persons die each year from conditions attribiitai)le to the dru,,
Less harmful but still disti-essiii,, is the effect of tetracycline and
its aiialogties oii the permanent teeth when the drug is i,,,eii to Notin(i children oi- pregnant women. A stable calciuiii c-oinpotind is
formed in bony
45 Dr. Roger J. Bulger, "A Methicillin-Resistant Strain of Staph
ylococcus Aureus," Annals of Internal Ifpdicirte, 67:81, 1967.
46 I>r. Robert S. Nlyers, "ne \Iisuse of Antil)actei-ials in Iii~niin~il
Herniorrapby," Siirgeril, Gynecology, and Obstetrics, 108:721-728,
1949.
47 The latest survey (at jobns Hopkins Hospital) was reported in
Archives of Interrwl Aledicine, 121:1-10, 1949.
56
The Medicine Men
tissues. That's of 1-io importance anywhere but in the teeth. The
permanent teeth may take on a peculiar filthy gray or yellow-brown or even
fluorescent orange appearance. You'd think then that no doctor would
prescribe such drugs for children, wouldn't you? But they do, and the same
pharmaceutical manufacturers who insert the legally-required warnings
about tooth discoloration in the packages also supply a variety of forms
of the tetracyclines made especially for children (flavored syrtips, drops
and so forth). If doctors wouldn't order them, the drug companies wouldn't
make them. Not oiil,- do the doctors order them, but they object when the
Food and Drug Administration takes them off the market. Over 3000 letters
of protest came from physicians when pediatric drops containing
tetracycline %,.-ere banned.
Other antibiotics are harmful in their own way. Streptomycin can cause
damage to the eighth cranial iierx-e, resulting in dizziness, noises in
the head and deafness. Triacetylandomycin may lead to liver damage and
jaundice. Polymyxin may be toxic to the kidneys.
Instead of whirling around his head magic beads to drix-e away disease,
the doctor now brandishes an effecti%,e sword that damages more than
bacteria. But he has to be aware that the sword is double-edged.
So does the patient. if you've got an infected hang
p
nail or an annoying cough, don't ask the doctor for an antibiotic. Most
times he'll be only too willing to oblige. You can also refuse to take any
antibiotic unless it is clear to you that you have a serious illness and
nothing else will do. That sounds as though you're pitting your judgment
against that of the doctor's Why shouldn't you? It's your, not the
doctor's, health that is at stake.
Fashion has much to do with drug therapy. If, confronted by any one of the
varieties of psychic distress, the doctor didn't use the new psychotropic
(having an effect on the psyche) drugs, his patients might regard him as
an old fogey. The popular press is presently excited about the abuse of
these drugs but calmly ac
cepts their use. Indeed, the press shares responsibility for initially
acclaiming the virtues of tranquilizers. (This word, formerly rarely used
except a ' s slang for a billyclub or a blackjack, came int~o the general
vocabulary as the result of the influence of advertising agencies.
Tranqiiilizer is supposed to mean a substance that makes people calm, as o
'posed to sedative, which p
quiets them. The distinction is nebulous.) Tranquilizers are prescribed in
large quantities, as are the socalled psychic energizers. Effective
medications? Certainly. And dangers from their use? Of course.
The phenothiazii-ics, of great value in the treatment of some severe
neuroses and psychoses, may cause changes in the retina of the eye, almost
to blindness. More common, especially in children (where one of the
phenothiaziiies is used to control vomiting) is rigidity of the neck and
muscular twitchings approaching convulsive mox-enients. Most common is the
development of psetido-Parkinsonism, the syndrome characterized by
rigidity, tremors, bead-nodding and short-stepped gait. Very recently, Dr.
Carl S. Alexander reported at a meeting of the American Heart Association
that longterm users of the phenothiazines face possible heart
abnormalities (enlarged b6arts, irregular heart beats .and myocardial
infarctio'n). Discontinuance of the drugs, be said, may cause improvement
in the condition, but cardiac damage and residual abnormal
electrocardiographic changes may persist for months.
Meprobamate, sold under the registered trademarks of Miltown and Equanil,
is effective-and habituating. After it is taken for a while and then
stopped, withdrawal symptoms may occur: vomiting, incoordination, muscle
twitching, even epileptiform seizures.
The most dramatic side effects occur with the group of psychic energizers
known as monamine oxidase inhibitors. Useful in the treatment of mental
depressions, they can cause acute high blood pressure reactions, sometimes
fatal ones. They also are dangerous if the patient eats cheese, pickled
herring, chicken livers, canned figs, or if he takes a cough syrup or a
cold tablet
Cauldron
containing antihistamines. Sometimes I wonder if it's worthwhile to
substitute for the depression the fear with which a patient approaches his
table. Dr. Richard Hunter, a British psychiatrist, says, "As psychotropic
drugs multiply and doctors prescribe them like aspirin, it becomes more
important to take a thorough drug history than the time-honored sex
history. Today sex, largely stripped of guilt, seems to be much less toxic
or pathogenic than psychotropic drugs. Verbum sap.
Enlightened Americans who have no faitb in the curative powers of relics
are suckers for anything that smacks of a scientific short-cut to a
corpore sano. The heck with the mens sana! Let a Boston lady find out that
prayers did her more good than physicians when she was ill (undoubtedly
true in her time and frequently in ours), and a new religion is born. Let
a respected psychoanalyst announce the discovery of a new kind of energy
and followers flock to him to be recharged in modified telephone booths.
Let a sciencefiction writer proclaim a physiologic basis for the merits of
confession and be becomes the prophet of a new creed. (Dianoetics has now
been elevated to scientology, a formal religion.) And let researchers
discover a chemical compound that stops inflammation, and hosannas arise
from the healing profession. joy spreads that at last disease can have no
victory. The universal panacea is here!
Cortisone and its modifications eliminate inflamniatory changes in
tissues. Acclaimed for its value in rheumatoid arthritis, its use was qiiickly extended to other morbid conditions. Doctors thought that was
logical: inflammation anywhere is pathologic; do away with inflammation
and the pathology disappears. They underestimate the self-righting powers
of the body. By adding new steroids they upset the balance of the hormonal
system. By the time the initial excitement had died down, the secondary
effects of cortisone preparations were well known: fatness and floridity,
exhaustion of the adrenal glands, susceptibility to infection, peptic
ulcers, delayed healing of wounds, degenerative changes in the bones,
stunting of growth and cataract formation in children, and a host of other
damaging conditions.
Do you think that doctors then severely restricted the use of steroids?
Do you think that if a witch doctor discovered a magic powder that
eliminated what the patient complained of he wouldn't use it? That's too
much to ask of him. There's enormous ego satisfaction to be derived when
applause is won from an audience.
57
The doctor continues to prescribe corticosteroids, telling himself he
knows what he is doing and he'll stop if trouble develops. He extends the
indications for their use until he no longer thinks twice about using it
for such minor conditions as allergic rliinitis. That's not killing a fly
with a sledge hammer; that's knocking it dead with a cannon.
When a doctor orders antibiotics, tranquilizers, or corticosteroids, he
knows he is going to get results. That assurance causes cerebral atrophy
in him-a side effect unmentioned in the package inserts. NVliy spend time
on a painstaking diagnosis or why worry about clinical judgment when such
fine remedies are at hand for whatever ails the patient?
Untoward effects occur with many drugs of lesser value. Some of the
effects disappear when the drug is discontinued; others persist. Example:
chloroquiiioiie (used in arthritis and iiialaria) frequently causes
permanent eye damage. Another example: Of 34 patients receiving
indomethaciii (used in artliritis), all had redticed visual aciiity aiid
all improved ~,-.,Iieii the drug was stopped. " Cblortbalidone effectixeln- used iii the treatment of high blood pressure also effectively caused
gout in ten per cent of the cases. Other aiitihypertensive drugs cause the
surfacing of lateiit diaI)etes or actually bring on diabetes.
Doctors are as brainwashed as the general public when it comes to drugs.
They believe the propaganda of the pharmaceutical manufacturers that
specific brands have virtties. They prescribe by brand names. They argue
that the first criterion in the selection of a drug should not be its
cost; they value the reputation of the maker more than the cheapness of
the same drug from another firm. Senator Gaylord Nelson stated in
exasperation, "They [the Pharmaceutical Mantifacttirers Association] spend
$4000 per year per physician to convince doctors all over the country they
can't trust generic drugs. Yet every time I ask physicians about the wide
price differences, why Schering sells its brand of prediiisoiie at $17.90
retail and offers it on bid for $1.20 to the city of New York-the doctors
just don't know . . . ... But they fight, jtist the same. They resent the
intrusion of government agencies into their divine right of prescribing.
If they knew what happens in the body to the drugs they were prescribing,.
their anger would be justified.
4 " Dr. Charlotte A. Burns, American Jourrwl of OI)htlialniology, 66:
825, 1968.
But they don't. And Dow I'm not talking about side effects, but about
pharmacology. Example: A doctor has a diabetic patient with heart disease,
whose diabetes is controlled by tolbutamide; the patient develops swelling
of the legs and is given ethaerynic acid to get rid of the fluid; he
promptly goes into hypoglycemia, a condition resembling insulin shock; the
diuretic intensified the action of the tolbutamide. Another diabetic is
taking acetohexamide; his doctor prescribes phenylbutazone for his
arthritis; again-hypoglycemia. Even the anesthetic given during an
operation may cause kidney failure and death if the patient has taken
tetracycline before surgery." The combination of drugs may cure the
disease but kill the patient. Years ago it was demonstrated that a patient
in heart failure taking digitalis should not be given calcium
intravenously because of the danger of sudden death from electrolytic
changes in the heart muscle. Yet I have beard a doctor advise intravenous
calcium to stop the leg cramps caused by a strong diuretic in a dropsical
digitalized patient.
A note of caution. The drugs have value, but they cannot be used
mindlesslv. The doctor must take the time to read the medical ~ata about
them and to learn their potential for harm. He, equally with his patient,
must not be on the lookout for something new merely becai-ise it's new.
Sowben the doctor says, "I'm going to try this new stuff on you that just
came out," tell him, "No, thanks. Try it on the dog,"-if you don't like
dogs.
2.
Let's leave the new drugs. What's old? Blood, for example, which carries
with it overtones of cannibalistic rites. "In the blood is the life," says
the Bible. Also death and illness. "Transfusions are still one of the most
dangerous forms of medical therapy," states Dr. Aaron M. Josephson of the
Michael Reese Research Foundation and Blood Center in Chicago.
Transmission of hepatitis, syphilis and malaria are possible hazards of
blood transfusions, but more important are sensitization to blood
antigens, unpredictable sbock-like reactions, and hemolytic changes. A
significant alteration occurs in whole blood stored in blood banks; there
is an increase of plasma potassium, plasma ammonia, inorganic phosphates
and free plasma hemoglobin, besides a heightened alkalinity of the blood.
The altered blood is often deleterious to patients with heart, liver and
kidney ailments, to old people and to infants. And yet how many times have
families expected and have their doctors ordered blood to be given to the
unfortunate
The Medicine Men
patient "just to make sure?"
3.
What else does the doctor do to help his patients get
well? He uses instruments for diagnosis and treatment, not gourds or sand
paintings, but ingeniously devised tubes and mirrors. Without them he'd be
at a loss. Without them he could not photograph the arterial supply of the
brain or map the chambers of the heart or supply air to damaged lungs and
nutrition to unconscious patients. The doctor knows the hazards of such
treatment, but in his zeal to do good be brushes that knowledge aside.
Tracheostomy is the making of an artificial opening in the windpipe so
that oxygen maN- be more easily administered, under pressure, if need be.
The operation has become almost routine in badly burned or severely
injured patients. "The major fatal complication is no longer wound sepsis
[infection] but pneumonia. The decline in wound infection is due to eff
ectix,,e topical chemotherapy [local application. of chemicals that kill
germs], and the rise in fatal pneumonia is probably due to the effects of
earlier and more prolonged ventilatory assistance and oxygen therapy ...
Tracheobroncliitis is the most frequent finding in the lungs of burned
patien.ts. The focal ulcerative laryngeal and tracheal lesions seen are
clearly related to tracbeostomy rather than to inhalation therapy . . . .
~" In other ,-,,ords, in their zeal to help the severely burned patient,
the doctors have overreached themselves and bax-e ended up with harming
him. Enough said.
Bladder catheterizations, often done to save bed linens and wear and tear
on nurses, accounted for 40% of hospital-acquired infections in the Johns
Hopkins survey previously quoted. That percentage does not include
infections after diagnostic cystoscopies.
The routine use of intravenous infusions for support and nutrition,
conveniently provided now by plastic indwelling tubes, has brought on
almost an epidemic of septic phlebitis, inflammation of the vein in which
the tube is lodged. The growth of bacteria in one part of the circulatory
system then is frequently followed by septicemia. In burned patients
especially, an eighteenmonth study by the Army Surgical Research Unit at
Fort Sam Houston, Texas, disclosed that post-phlebitic septicemia caused
the death of 12clc of those autopsied. A Harvard study in 1968 showed a
34.3~Ic incidence of
50 Capt. F. Daniel Foley, M.C., Col. John A. ),Ionerief, NI.C., and Dr.
Arthur D. Mason, Jr., "Pathology of the Lung in Fatally Burned Patients,"
Annals of Surgery, 167:251-264, 1968.
49 Dr. E. Y. Kuzucku, in the Journal of the Anierican ~ifedical
Association, 211:1162, 1970.
Cauldron
local infection from polyethylene catheters, 17.4~'c with pathogens, 16.9(
with contaminants. Phlebitis occurred in 39~Ic of the patients and
bloodstream infection in three patients, two of whom died therefrom. The
risk of infection and bacteremia was directly related to the dtiration of
catheterization.
NN-heii the medicine man approaches with his paraphernalia, maybe the
cringing patient should cry out, "Don't do me any favors!"
To put it bluntly, do not submit yourself to having instruments and
devices pushed into natural or artificial orifices without good and
sufficient reason. The doctors may call you uncooperative, So what? Names
will never hurt you. The catheters may.
4.
That's for treatment. It's worse when sickness follows diagnostic
procedures like angiograms, cardiac catheterizations or pyelograms. They
are not entirely innocuous. Arteriography, the visualization of arterial
circulation, one of modern medicine's most imaginative techniques, should
not be used routinely in diagnosis, warns Dr. William Likoff, Professor of
Medicine and Director of the Cardiovascular Institute at Habnemann Medical
College in Philadelphia. He says, "It is a sophisticated, expensive
procedure fraught with danger and requiring hospitalization ... The
physician can inadvertently destroy the artery or cause the formation of a
clot ...... When multiple angiograms using a contrast medium are used in
infants, there is a grave risk of renal medullary necrosis, a fatal
disorder." Besides the dangers of infection and allergic reactions (often
piously referred to as "an act of God," thereby removing the blame from
the doctor and placing it on the Blameless One), the instrument that is
being used may perforate the part being examined. Such accidents, although
rare, happen often enough for patients to be wary of examinations "just
for the record."
The antics of the witch doctor may be comical to behold and may not do
much good, but at least he can't be held responsible if his patient gets
sicker or dies. His jumping around diddt do that.
5. "WE DID OUR BEST"
A young man had an acutely inflamed throat. He went to his doctor, who
gave him an injection of penicillin. The sore throat quickly got better.
Three days later, the young man began to itch. The itching got worse and
he developed hives all over his body. The doctor made the correct
diagnosis of an allergic reaction to penicillin. He prescribed antihista
mines. The hives disappeared.
The young man, a machine operator, got drowsy from the antihistamines and
cut his hand at work. The nurse in the dispensary gave him first aid and
put on an anti-bacterial ointment containing penicillin. The hives
returned and now the young man had swelling of the eyes and lips. The
doctor recognized that a potentially dangerous allergic reaction was
present; he ordered a course of corticosteroid treatment. Result-the
itchiness, the hives and the swellings disappeared and the patient was
well again.
Except that now he had pain in his belly plus heartburn, and he began to
show signs of blood in his stools. The correct diagnosis of a peptic ulcer
(induced by the corticosteroid) was made. The young man did not do well on
medical treatment; he continued to bleed from his ulcer. His doctor,
therefore, bad a surgeon in consultation. The two doctors agreed that
partial gastrectomy was necessary, an operation to remove the ulcerbearing portion of the stomach. The operation was successful.
But because of the previous bleeding and the unavoidable blood loss at the
operation, a transfusion of 1000 milliliters (two pints) of blood was
given. Hepatitis (inflammation of the liver) followed. The young man
became intensely jaundiced; be vomited his food and had to be fed
intravenously for a few days. His youth did him in good stead. He
recovered from his hepatitis.
At the right ankle, where the intravenous needle and the plastic tube bad
been inserted into a vein exposed by cutting through the skin, a tender
nodule appeared. It became red and inflamed, evidence of infection.
Because of the bad experience the patient bad had with penicillin, the
doctor prescribed tetracycline. The inflammation promptly subsided.
Because of the antibiotic, diarrhea came on and the patient had severe
colicky cramps. The doctor ordered a special diet and gave a new synthetic
antispasmodic drug to control the cramps. Diarrhea stopped.
The new drug was in the belladonna class. It relaxed smooth muscle all
over the body, and by its action on the iris, it caused dilatation of the
pupil.
The young man's vision was impaired. He drove his car into a tree. Exitus
young man.
This is a true story.
51 Reported by Dr. Alan B. Gruskin, director of pediatric nephrology at
St. Christopher's Hospital for Children, Philadelphia, basing Itis finding
on histologic studies of 34 infants who died after diagnostic angiography
to evaluate congenital heart disease.
60
The Medicine Men
Advice From an Infidel
"Knowledge is the principal thing; therefore get kiionvledge: and NN7itli
all t]iN- ,ettiiig get understanding." Proverbs, 4:7
Is N-our flesh crawling? I hope so. I hope I have instilled some doubt
into you, some doubt about the efficacy of the ceremonials of American
medicine men. In doubt lies the beginning of wisdom.
If x~oti can't put faith in your doctor, what can you do'-' First, forget
the faith. That word shouldn't apply to doctors. Next, do some hard
thinking. You want physical iiiimortality, of course. Well, that's
impossible. Then do you want to prolong the years of your life? Not at
all, if that means being blind, deaf, doddering, incontinent, a stinking
Struldbrug, a painful burden to your children, a living inemento i7wri.
You want to live in full possession of your faculties, to enjoy eatiiicy
and drinking and sex, to be vigorous and alert.
So how do you achieve those glorious goals? I can offer you a few guide
points.
Don't regard your doctor as a wizard but as a niortal man who sees in the
world a microcosm of ailments. And because of his specialized vision
remember that he is sliortsi(rlite(l. He xn,aiits to solve one problem and
he often can, but to -,N71iat end? NN'liat's the use of treating
ilietiiiiatoid artliritis NN,itli effecti\,e aiitiiiialarial drugs if
blindness ii-tay occtti-? NN']iNorder iodized salt to prevent ,~oiter and
end tip with severe aciie in adolescents? lIoNNvaluable is an orcyaii
transplant -,N,Iieii the coijclitioii that caused the trotil)le in the
original oi-glill persists ( as arteriosclerosis, in the case of Di-.
Blail)ei-g) ?
Don't expect more of the doctoi- than an honest and iiitelli(,eiit
application of his leariiii)g. That means what lie does lie should do well
and wliat lie can't do lie slioti](I let alone or (,et help in doing it.
It also means that lie should not order laboratory work as a routine
\N,itliotit specific need for it, and he should explain its iiecessitn- to
.-oti.
Don't ask him to work miracles. He cannot resurrect the dead iioirestore power to linil)s paralyzed by severance of the spiiial cord. He
cannot foretell the exact hour of birth nor prognosticate the moment when
life will depart. He cannot make the blind see without eyes, nor tl-ie
deaf hear without auditory nerves. He
can't e\,ei) promise your backache \x-ill not i-ectir nor ,,,our litir not
turn gray.
Don't foi-tret there are no top secrets in medical care. Doctors like to
cro\N, al)otit their sticc,esses: they hasten to I)til)lisli tlieii- good
results. Once ~t pi-ocediii-e is no
~7)
loii,,ei- experimental, its use becomes iii)i\-ei-sal. Once a di-ti,,
est~il)lislies its iiierit, eNer\, (loctoi- will prescribe it \N,Iieii it
is ii)(licated. OiilN,, charlatans pi-eteiid to have secret remedies. The
(la\7 after the clti-e for cancer is (liscoN-ei-ed, \-Our doctor will know
about it. Don't think ~iii\,oiie else kiio\N-s iio\N, and won't tell.
Don't demand of the doctor the tenderness and love ~-oti may
iiiissiii(j- in votir life. "A kiss on your hand makes \7ott
but a diamond bracelet lasts a long time." The doctor is not
for wife or ii-iother or I)iisl)aiicl or father. His jol) is
well and fit.
be
feel (,ood
a substitute
to keep you
That means a radical change in your attitude toward doctors. Don't be a
gttllil)le participant in the s6aiice. Don't regard doctors as wizards,
omniscient and possi1)1\- omnipotent. Renieiiil:)er the dialectic
relationship: \"Iitliotit voti lie wotildii't be a doctor. Therefore-don't
let N-otir I)odN- I)e poisoi-ied by paradoxically useful and tiseless
drugs. Ask, ask, ask about the dangers in the prescriptions. Let the
doctor think you're an overcautiotis iitit. His opinion won't hurt you as
much as a liarniftil medication. Don't submit yourself to diagiiostic
procedures of doubtful value and doubtless possil)ilities for, hari-i-i.
Insist oi-i knowing why they are being ordered. Don't be a guinea pig for
the latest medical fads just because the joneses are falling for them. And
don't go to the other extreme-don't set \,our itidgmerit against your
doctor's as to what is good and what is ])ad in medicine. Presumably he
gets his information from better sources than you do. just make sure be
knows what lie is doing ai-id why. Your own common sense must be used. If
a technique or a procedure or a drug doesn't make sense to you, ask your
doctor to explain. Don't be put off by medical double-talk; if he says you
won't understand, rest assured he doesn't ei
Advice From an Infidel
ther. Making him speak straight English will make him oftener so much in a
hurry that they do instead of
think straight too.
Don't think that by stiing the doctor when he makes a mistake that yoii're goina to improve the qualit-,7 of medical care. All you're doing is
making his malpractice insurance rate go up and that expense is inevitably
-added to ~rotir ])ill. \Ialpractice su:ts make lawyers richer, not you
healthier. You're mistaken if you think a le,,al jtidgment can alter a iiiystic ritual.
Don't i~iiterfere in the doctor's practice, except to poke fun at his
antics. You don't know the details of what is necessary to turn the art
into a science. Wellr~ieaiiiiig reformers tried to cure alcoholism by
Prohibit-loii and ended tip with Capone. Demai-idiiig medical care audits,
uniformity of records, compulsory laboratory teStiDg-all lead to an
increase of l~)urdensome bureaucracy and an increase in the cost of
medical care, not in its quality. Likewise, don't get carried away I)x,
the idea that So\-iet-style polyclinics or Britisb-style panel medicine
will automatically bring about superior medical care. '\IaN,I)e you won't
have to wait so long for the witch doctor to come, but when he does he'll
have the same old bag of tricks. Nor is prepaid health insuran(,e the
answer. What difference will it make if the witch do~,tqr,:- -oid by the
state if the mummery's the same?
Remember that, altho~,igh doctors make a great deal of moiie),, iiione),
is seldom their sole aim when they treat you. They actually want you to
get well. Don't attribute mercenary motives to tliei-i-i when they advise
an operation or diagnostic tests. just be sure that the
--~---feasons they give for those procedures make sense to vou. Doctors
are Dot conscious charlatai-is or ignorant irauds, but they are often
intellectually lazy and even
think.
Change doctors if the one you have is not candid with you. Change if his
treatment is not giving results or if it has added complications to what
you started with. Chai-ige if he promises miraculous cures. Change if he
treats you like a child or an idiot. Change if he gets angry when you
question him about his diagnosis or treatment. There are plenty of good
doctors around. You have to look for them and from personal experience I
can tell you the search will not be easy, but it is well worth the
trouble.
"Every country has the government it deserves" runs the adage. And every
country has the doctors it deserves. If y*ott want to get away from
witchcraft, start throwing out your own superstitions. Be open-minded and
receptive to fresh ideas. If you hanker for the good old days when Doc
tramped through the snow carrying a heavy black bag, you'll keep right on
being satisfied with Doctor in a shiny office radiating sympathy. What's
needed in this country is a new kind of medical practice, one that won't
be dependent on your good will oi- your willingness to be amused, one
whose function will be to prevent illness and to cure or alleviate those
illnesses that cad't be prevented, one that will help you to reach your
goal of a long, happy and healthy life.
flow that will come about I don't know, but I do know that an intelligent,
informed public can help to eliminate much of the ceremonial nonsense that
attends present-day ryiedical practice.
I didn't mean to eiid by giving advice but I did, ann,way. That's what
comes of being a doctor for so long. Out of habit I clon the mask and give
a solemn opinion.
Do you trust your doctor? Does he really know what he's doing? To most
Americans, the answer to such questions is an immediate "Of course," and
to this extent our blind faith in the wisdom and powers of physicians is
little different from the belief of primitive peoples in their witch
doctors' incantations and spells.
THE MEDICINE MEN is a well-documented and witty book which explodes the
myth of quality medical care in the United States. Dr. Leonard Tushnet, a
respected doctor of almost forty years' experience, here analyzes many of
the recent "breakthroughs" in medical technology, diagnosis and treatment,
and finds that they' have been dangerously overemphasized and not fully
understood by many in the medical profession. THE MEDICINE MEN gives the
layman an insider's view of both general practitioners and specialistsinternists, obstetricians, psychiatrists, gynecologists and surgeons,
among others-and some of their commonly used and often dangerous
treatments. The author also casts serious doubt on the effectiveness of
some of our most honored articles of medical faith: the annual check-up,
laboratory ''tests," and medical "consultations. ''
This is a book which pulls no punches. It is not an indictment of all
doctors, but it does offer sound advice on how to tell a competent
physician from a highly educated witch doctor. THE MEDICINE MEN is a book
which could conceivably save your life, and is required reading before you
keep your next appointment with your doctor!
Dr. Leonard Tushnet has recently retired from his New Jersey Medical
practice after almost forty years of service. He is the author of
numerous medical and historical articles, and has had more than sixty
short stories published in the past ten years. Two of his previous books
have dealt with the history of the Warsaw Ghetto.
THE MEDICINE MEN is his first full-length analysis of the profession to
which he has devoted most of his life.
Jacket design by
John-C-,---,h
CONSUMER EDUCATION RESEARCH GROUP P.O. BOX 336 SO ORANGE, N.J. 07079