Chapter 39

PREVENTIVE "HUMANIZED" MEDICINE: PHYSICIAN AND TEACHER

No profession, excepting possibly the ministry, is regarded with greater deference than the medical profession. Our ancestors listened with awe and obedience to the warnings and behests of the medicine man, bloodletter, bonesetter, family doctor. In modern times doctors have disagreed with each other often enough to warrant laymen in questioning the infallibility of any individual healer or any sect, whether homeopath, allopath, eclectic, osteopath, or scientist. Yet to this day most of us surround the medical profession or the healing art with an atmosphere of necromancy. Even after we have given up faith in drugs or after belief is denied in the reality of disease and pain, we revere the calling that concerns itself, whether gratuitously or for pay, with conquering bodily ills.

Self-laudation continues this hold of the medical profession upon the lay imagination. One physician may challenge another's faults, ridicule his remedies, call his antitoxin dangerous poison, but their common profession he proudly styles "the most exalted form of altruism." Young men and women beginning the study or the practice of medicine are exhorted to continue its traditions of self-denial, and in their very souls to place human welfare before personal or pecuniary advancement. Newspapers repeat exhortation and laudation. We laymen pass on the story that we know is not universally true,--physicians know, physicians apply what they know without consciousness of error, physicians must be implicitly trusted.

For a physician to give poison when he means to give food is worse, not better, than for a layman to make the same mistake. Neither the moral code nor the law of self-preservation enjoins a tuberculous mother to take alcohol or to sleep in an unventilated room, even if an uninformed physician prescribes it. Instruction in physiology and hygiene would be futile if those who are educated as to the elementary facts of hygiene and physiology must blindly follow blind physicians. A family doctor who gives cod-liver oil for anæmia due to adenoids may do a child as much harm as a nurse who drugs the baby to make it sleep. The physician who refuses to tell the board of health when smallpox or typhoid fever first breaks out takes human life just as truly as if he tore up the tracks in front of an express train. This is another way of saying that parents and teachers must fit themselves to know whether the family physician and their community's physicians are efficient practitioners and teachers. Every one can learn enough about the preventable causes of sickness and depleted vitality to insist upon the ounce of education and prevention that is better than a pound of cure.

For its sins of omission, as for its sins of commission, the medical profession shares responsibility with laymen. For years leading educators, business men, hospital directors, public officials, have known that communicable diseases could be stamped out. The methods have been demonstrated. There is absolutely no excuse to-day for epidemics of typhoid in Trenton, Pittsburg, or Scranton, for epidemics of scarlet fever in the small towns of Minnesota, for uninterrupted epidemics of tuberculosis everywhere. Had either laymen, physicians, or school-teachers made proper use of the knowledge that has been in text-books for a generation, this country would be saving thousands of lives and millions of dollars every year. Our _doing_ and _getting done_ have lagged behind our _knowing_.

The failure of physicians to "socialize" or "humanize" their knowledge is due to two causes: (1) no one has been applying _result tests_ to the profession as a whole and to the state in its capacity as doctor, testing carefully the sickness rate, the death rate, and the expense rate of preventable diseases; (2) physicians themselves have not needed to know, either at college or in practice, the tax levied upon their communities by preventable sickness. Public schools can do much to secure result tests for individual physicians, for the profession as a whole, and for boards of health. Schooling in preventive medicine, or, better named, schooling in preventive hygiene, will fit physicians to do their part in eradicating preventable disease.

Preventive hygiene is not an essential part of the training of American physicians or nurses to-day. Not only are there no colleges of preventive hygiene, but medical schools have not provided individual courses. It is possible for a man to graduate with honors from our leading medical colleges without knowing what "vital statistics" means. Even boards of health, their duties and their educational opportunities, are not understood by graduates; it is an accident if the "social and economic aspects of medical practice," "statistical fallacies," "hospital administration," "infant mortality," are familiar terms. It is for this reason, rather than because physicians are selfish, that indispensable and beneficent legislation is so generally opposed by them when the prerogatives of their profession seem in danger. Practically every important sanitary advance of the past century has been fought at the outset by those whose life work should have made them see the need. Physicians bitterly attacked compulsory vaccination, medical inspection of schools, compulsory notification of communicable diseases. What is perhaps more significant of the physician's indifference to preventive hygiene is the fact that most of the sanitary movements that have revolutionized hygienic conditions in America owe their inception and their success to laymen, for example, tenement-house reform, anti-child labor and anti-tuberculosis crusades, welfare work in factories, campaigns for safety appliances, movement for a national board of health, prison, almshouse, and insane-asylum reform, schools for mothers, and milk committees. The first hospital for infectious diseases, the first board of health, the first out-of-door sea-air treatment of bone tuberculosis in the United States, were the result of lay initiative.

Dr. Hermann M. Biggs says that in America the greatest need of the medical profession and of health administration is training that will enable physicians and lay inspectors to use their knowledge of preventive hygiene for the removal of living and working conditions that cause preventable sickness. A physician without knowledge of preventive hygiene is simply doing a "general repair" business.

For a few months in 1907 New York City had a highly efficient commissioner of street cleaning, who, in spite of the unanimous protests and appeals of the press, refused to give up the practice of medicine. Hitherto the board of health of that city has been unable to obtain the full time of its physicians because professional standards give greater credit to the retail application of remedies than to the wholesale application of preventives.

Statesmanship as well as professional ability is expected of physicians in the leading European cities, more particularly of those connected with health departments. There it is not felt that a medical degree is of itself a qualification for sanitary or health work. After the professional course, physicians must take courses in preventive hygiene and in health administration. Medical courses include such subjects as vital statistics, duties of medical officers of health, sanitary legislation, state medicine.

The needless cost for one year of "catching" diseases in New York City would endow in perpetuity all the schools and lectureships and journals necessary to teach preventive hygiene in every section of this great country. That city alone sacrifices twenty-eight thousand lives annually to diseases that are officially called preventable. The yearly burial cost of these victims of professional and community neglect is more than a million dollars. When to the doctor bills, wages lost, burial cost of those who die are added the total doctor bills, wages lost, and other expenses of the sick who do not die, we find that one city loses in dollars and cents more every year from communicable diseases than is spent by the whole United States for hospitals and boards of health.

Many diseases and much sickness are preventable that are not communicable. Indigestion due to bad teeth is not itself communicable, but it can be prevented. One's vitality may be sapped by irregular eating or too little sleep; others will not catch the trouble, although too often they imitate the harmful habits. Adenoids and defective vision are preventable, but not contagious. Spinal curvature and flat foot are unnecessary, but others cannot catch them. Preventive hygiene, however, should teach the physician's duty to educate his patient and his community regarding all controllable conditions that injure or promote the health.

In the absence of special attention to preventive medicine new truth is forced to fight its way, sometimes for generations, before it is accepted by the medical profession. So strong are the traditions of that profession and so difficult is it for the unconventional or heterodox individual to retain the confidence of conservative patients, that the forces of honorable medical practice tend to discourage research and invention. The man who discovers a surgical appliance is forced by the ethics of his profession either to commercialize it and lose his professional standing, or to abide the convenience of his colleagues and their learned organizations in testing it. Rather than be branded a quack, charlatan, or crank, the physician keeps silent as to convictions which do not conform to the text-books. Many a life-saving, health-promoting discovery which ought to be taken up and incorporated into general practice from one end of the country to the other, and which should be made a part of the minimum standard of medical practice and medical agreement, must wait twenty-five or fifty years for recognition.

For want of a school of preventive medicine to emphasize universally every new truth, the medical colleges are permitted to remain twenty-five or fifty years behind absolutely demonstrated facts as to medical truth and medical practice. In 1761 a German physician, Avenbruger, after discovering that different sounds revealed diseased tissue, used "chest tapping" in the diagnosis of lung trouble. In 1815 Lëannec discovered that sound from the chest was more distinct through a paper horn. On that principle the modern stethoscope is built. He made an accurate diagnosis of tuberculosis, and while suffering from that disease treated himself as a living clinical study. In 1857 Pasteur proved the presence of germs "without which no putrefaction, no fermentation, no decay of tissue takes place." In 1884 Trudeau started the first out-of-door care of pulmonary tuberculosis in America. In 1892 Biggs secured the compulsory notification of pulmonary tuberculosis. In 1904 began our first out-of-door sea-air treatment for bone tuberculosis. Yet there are thousands of physicians to-day who sincerely believe that they are earning their fees, who, from houses shut up like ovens, give advice to patients for treatment of tuberculosis, who prescribe alcohol and drugs, who diagnose the disease as malaria for fear patients will be scared, who oppose compulsory registration, and who never look for the tuberculous origin of crippled children. Just think of its being possible, in 1908, for a tuberculous young man of thirty to pay five dollars a day to a sanatorium whose chief reliance is six doses of drugs a day!

In 1766 America's first dentist came to the United States. By 1785 itinerant dentists had built up a lucrative practice. In 1825 a course of lectures on dentistry was delivered before the medical class at the University of Maryland. As early as 1742 treatises were written "Upon Dentition and the Breeding of Teeth in Children." In 1803 the possibility of correcting irregularities was pointed out, as was the pernicious effect of tartar on the teeth in 1827. In 1838 attempts were made to abolish, "in all common cases, the pernicious habit of tooth drawing." In 1841 treatises were written on the importance of regulating the teeth of children before the fourteenth year and on the importance of preserving the first teeth. Yet in 1908 it is necessary to write the chapter on Dental Sanitation. Few physicians, whether in private practice or hospitals or just out of medical college, consider it necessary to know the conditions of the mouth before prescribing drugs for physical illness.

Osteopathy furnishes an up-to-date illustration. Discredited by the medical profession, by medical journals and medical schools, it has in fifteen years built up a practice of eight thousand men, having from one to three years' training, including over one hundred physicians with full medical training plus a course in osteopathy. There were means of learning fifteen years ago what was truth and what was quackery about the practice of osteopathy. By refusing to look for its truth and by concentrating attention upon its quackery the medical profession has lost fifteen years. Whereas the truth of osteopathy should have been adopted by the medical colleges and a knowledge of its possibilities and limitations required of every practicing physician, a position has been reached where alleged quackery seems in several important points to be discrediting the sincerity, the intelligence, and the efficiency of orthodox medicine. No appeal to the natural can be stronger, no justification of schools of preventive medicine more complete, than the following paragraph from an osteopathic physician who is among the small number who, having both the medical and osteopathic degrees, see both the possibilities and limitations of manual surgery and demand the inclusion of this new science in the medical curriculum.

The physical method of treating disease presents a tremendous and significant departure from the empiricism of medicine and the experimentation of dietetics, the restricted fields of electricity, suggestion, water cures, and massage. The patient as an individual is not treated; the disease as a disease is not treated; the symptoms are not treated; but the entire physical organism, with its many parts and diverse functions, is exhaustively examined until each and every abnormal condition, whether of structure or of function, causing disease and maintaining symptoms, is found and administered to with the skill of a definite art, based upon the data of an exact science.

Likewise the truths underlying Christian Science have been disdained by medical schools and medical experts, just as its spiritual truth has been disdained by religious leaders, until it has grown to such strength that laymen are almost forced to question the sincerity and the efficacy of the conventional in religion as well as medicine. In May, 1907, the Emmanuel Church in Boston organized a clinic for the purpose of utilizing for neurasthenics particularly both the spiritual and the physical truths underlying religion and the various branches of medical science. Daily papers and magazines are giving a great deal of space to this experiment in "psychotherapy," which is discussed in the chapter on Mental Hygiene. Schools and chairs in preventive hygiene would soon give to the medical profession a point of view that would welcome every new truth, such as the alliance of religion and medicine, and estimate its full worth promptly. Truth seeking would be not only encouraged but made a condition of professional standing.

Just what attitude any particular physician takes can be learned by the teacher or parents whose children he treats. If he pooh-poohs or resents board of health regulations as to isolation of scarlet-fever patients, he is a dangerous man, no matter how noble his personal character. If he says cross-eyes will straighten, weak eyes will strengthen, or nose-stopping adenoids "absorb," he is bound to do harm. If he says tuberculosis is incurable, noncommunicable, hereditary, or curable by drugs, or if he tries to cure cancer by osteopathy, he can do more injury than an insane criminal. If he fails to teach a mother how to bathe, feed, and clothe the baby, how to ventilate a room for the sick or the well, he is an expensive luxury for family or for school, and belongs to an age that knew neither school nor preventive hygiene. If he takes no interest in health administration; if he overlooks unclean milk or unclean streets, open sewers, and unsanitary school buildings, street cars, churches, and theaters; if he does not help the health board, the public hospitals, the schools, the factory, and tenement departments enforce sanitary laws, he is derelict as a citizen and as a member of an "exalted profession." If he sees only the patients he himself treats or one particular malady, he is derelict as a teacher, no matter how charming his personality or how skilled in his specialty. If a school physician is slovenly in his work, if he spends fifteen minutes when he is paid for an hour, should the efficient school-teacher conceal the fact from her superiors because he is a physician? If private hospitals misrepresent facts or compromise with political evils for the sake of a gift of public money, their offense is more heinous because of their exalted purpose. The test of a physician's worth to his patients and to his community is not what he is or what he has learned, and not what his profession might be, but what happens to patient and to community. Human welfare demands that the medical profession be judged by what it does, not by what it might do if it made the best possible use of its knowledge or its opportunity.

A dispensary that treats more patients than it can care for properly is no better than a street-car company that chronically provides too few seats and too many straps. Unless physicians test themselves and their profession by results, we shall be compelled to "municipalize the medical man." Preventable sickness costs too much, causes too much wretchedness, and hampers too many modern educational and industrial activities to be neglected. If the medical profession does not fit itself to serve general interests, then cities, counties, and states will take to themselves the cure as well as the prevention of communicable and other preventable sickness. Human life and public health are more precious than the medical profession, more important even than theories and traditions against public interference in private matters. The unreasoning opposition of medical men to government protection of health, their concentration on cure, and their tardy emphasis on prevention have forced many communities to stumble into the evil practices mentioned in Chapter XVI. Incidentally, the best physicians have learned that the prosperity of their profession increases with every increase in the general standard of living. It is the man in the ten-room house not the man in one room who supports physicians in luxury. It is the healthy man and the healthy community that value efficient medical service.

Many American cities maintain dispensaries and hospitals for the poor. Whether they will go to the logical conclusion of engaging physicians to give free treatment to all regardless of income depends largely upon what the next generation of private physicians do. The state already says when a physician's training fits him to practice. It will soon expect him to pass rigid examinations in the social and economic aspects of his profession,--its educational opportunity, vital statistics, sick and death rates. Will it need to municipalize him in order to protect itself?

Obviously the teacher or parent should not begin cooperation with physicians by lecturing them or by assuming that they are selfish and unwilling to teach. The best first step is to ask questions that they should be able to answer:

What causes cholera morbus or summer complaint? When does milk harm the baby? How can unclean milk be made safe? Whose fault is it that the milk is sold unclean and too warm? What agencies help sick babies? What is the health board doing to teach mothers?

Or, if a school physician, the teacher can ask:

Why not remove these adenoids? What causes them? When will they disappear by absorption? What harm can they do in the meantime? How long would an operation take? Would it hurt very much? What would be the immediate effects? Why not act at once? What provisions are there in town for such operations? Why have the physicians paid so little attention to breathing troubles? What could your state do to interest physicians in school hygiene? Will the school physician talk to a mothers' meeting? What agencies will give outings to sick children? What dispensaries are accessible? Who is the proper person to organize a public health league?

Physicians love to teach. If teachers and parents will love to learn and will ask the right questions, all physicians can be converted into hygiene missionaries, heralds of a statesmanship that guarantees health rights to all.

LICENSING THE PRACTITIONER

Three parties are interested in setting a high standard for physicians, dentists, druggists, nurses, and veterinary surgeons--the profession itself, the schools that educate, and the general public on whom the arts are practiced. The schools and the practitioners are, for the most part, primarily interested in protecting a monopoly of skill. Their interest in restrictive legislation is analogous to that of the labor union which limits the number of apprentices. This trade unionism among professional colleges and professional graduates of these colleges has gradually developed a higher and higher standard that results in greater protection to the public. The first step is generally to demand that all persons entering a profession after a given date shall prove to the state their ability to "practice" without injury to clients. It is almost impossible to get such laws through unless the original law exempts all persons by whatever name, who are practicing the art in question at the time the law is passed. Whether we are speaking of medicine, law, dentistry, accountancy, osteopathy, or barbering, this has been the history of compulsory restriction and of state examinations.

As with regard to most other legislation, the enforcement of the law lags behind its definition. Moreover nothing is done after a man has passed a certain examination to see that he remains fit and safe to treat the public. Because no supervision is provided except on the day of examination, it is possible for men and women to fill their brains for a week or two weeks with the information necessary to pass what coaches and tutors have learned will, in all probability, be asked. Forever after, the public is left to protect itself. Out of this condition have arisen the evil, unethical, and unprofessional practices represented particularly by painless dentists, by ignorant or dishonest physicians, and by osteopaths and careless nurses.

The machinery for preventing these evils is discussed in Chapter XXIX. Suffice it here to present to parents and teachers the need for examination in advance of certification that will show whether or not those who make a livelihood by caring for others' health are equipped to mitigate rather than aggravate evils, and for further tests by which the public can learn from time to time which, among those professional men who are protected by the public against competition, continue to be safe. Finally, if, as will be clearly seen, it is desirable that what we call professional ethics persist and that self-advertisement be discouraged, society must, for its own protection, adopt some other means than epithets to correct the evils of self-advertisement and quackery. Even though we admit the responsibility of each citizen when he goes to the house of a private practitioner who has made no other effort to lure him thither than to place a card in the window, it must be seen that we cannot hold responsible for their choice men and women who receive through newspapers, magazines, or circulars convincing notices that Dr. So-and-So or the Integrity Company or the Peerless Dental Parlor will place at their disposal, at prices within their reach, skill and devotion absolutely beyond their reach at the office of an efficient private practitioner. Some way must be found by which departments of health will currently impose tests of methods and results upon physicians, opticians, pharmacists, manufacturers of medicine, and dentists.

As laymen become more intelligent regarding their own bodies and healthy living, it grows harder and harder for quacks and incompetents to mislead and exploit them. Better than any possible outside safeguard is hygienic living. Fortunately, we can all learn the simple tests of environment and of living necessary to the selection of physicians, dentists, and opticians, or other "architects of health" whose efficiency and integrity are beyond question.