Chapter VI: Faith Cure and Graft in Surgery

Suggestive Therapeutics Chief Stock in Trade--Advice of a Medical
College President--Disease Prevention Rather than Cure--Hygienic
Living--The Medical Pretender--"Dangerous Diagnosis" Graft--Great
Flourish of Trumpets--No "Starving Time" for Him--"Big
Operations"--Mutilating the Human Body--Dr. C. W. Oviatt's Views--Dr.
Maurice H. Richardson's Incisive Statements--Crying Need for
Reform--Surgery that is Useless, Conscienceless and for Purely
Commercial Ends--Spirit of Surgical Graft, Especially in the
West--Fee-Splitting and Commissions--A Nation of "Dollar-Chasers"--The
Public's Share of Responsibility--Senn's Advice--The "Surgical
Conscience."

I think we have enough before us to show why intelligent people become followers of fads. Seeing so many impositions and frauds, they forget all the patient research and beneficent discoveries of noble men who have devoted their lives to the work of giving humanity better health and longer life. They are ready at once to denounce the whole medical system as a fraud, and become victims of the first "new system" or healing fad that is plausibly presented to them.

And here a question arises that is puzzling to many. If these systems are fads and frauds, why do they so rapidly get and retain so large a following among intelligent people? The answer is not hard to find. The quacks of these fad schools get their cures, as every intelligent doctor of the old schools knows, in the same way and upon the same principle that is so important a factor in medical practice, _i. e._, _faith cure_--the psychic effect of the thing done, whether it be the giving of a dose of medicine, a Christian Science pow-wow, the laying on of hands, the "removal of a lesion" by an Osteopath, the "adjustment" of the spine by a Chiropractor, or what not.

The principles of mind or faith cure are legitimately used by the honest physician. Suggestive therapeutics is being systematically studied by many who want to use it with honesty and intelligence. They realize fully that abuse of this principle figures largely in the maintenance of the shysters in their own school, and it is the very foundation of all new schools and healing fads. The people must be made to know this, or fads will continue to flourish.

The honest physician would be glad to have the people know more than this. He would be glad to have them know enough about symptoms of diseases to have some idea when they really need the help of a physician. For he knows that if the people knew this much all quacks would be speedily put out of business.

I wonder how many doctors know that observing people are beginning to suspect that many physicians regulate the number of calls they make on a patient by motives other than the condition of the patient--size of pocketbook and the condition of the roads, for instance. I am aware that such imputation is an insult to any physician worthy of the name, but the sad fact is that there are so many, when we count the quacks of all schools, unworthy of the name.

The president of a St. Louis medical college once said to a large graduating class: "Young men, don't go to your work with timidity and doubts of your ability to succeed. Look and act your part as physicians, and when you have doubts concerning your power over disease _remember this_, ninety-five out of every hundred people who send for you would get well just the same if they never took a drop of your medicine." I have never mentioned this to a doctor who did not admit that it is perhaps true. If so, is there not enough in it alone to explain the apparent success of quacks?

Again I say there are many noble and brainy physicians, and these have made practically all the great discoveries, invented all the useful appliances, written all the great books for other schools to study, and they should have credit from the people for all this, and not be misrepresented by little pretenders. Their teachings should be applied as they gave them. The best of them to-day would have the people taught that a physician's greatest work may be done in preventing rather than in curing disease. Physicians of the Osler type would like to have the people understand how little potency drugs have to cure many dangerous diseases when they have a firm hold on the system. They would have some of the responsibility removed from the shoulders of the physician by having the people understand how much they may do by hygienic living and common-sense use of natural remedies.

But the conscientious doctor too often has to compete with the pretender who wants the people to believe that _he_ is their hope and their salvation, and in him they must trust. He wants them to believe that he has a specific remedy for every disease that will go "right to the spot" and have the desired effect. People who believe this, and believe that without doctoring the patient could never get well, will sometimes try, or see their neighbors try, a doctor of a "new school." When they see about the same proportion of sick recover, they conclude, of course, that the doctor of the "new school" cured them, and is worthy to be forever after intrusted with every case of disease that may arise in their families.

This is often brought about by the shyster M.D. overreaching himself by diagnosing some simple affection as something very dangerous, in order to have the greater credit in curing it. But he at times overestimates the confidence of the family in his ability. They are ready to believe that the patient's condition is critical, and in terror, wanting the help of everything that promises help, call in a doctor of some "new school" because neighbors told how he performed wonderful cures in their families. When the patient recovers speedily, as he would have done with no treatment of any kind, and just as the shyster M.D. thought he would, the glory and credit of curing a "bad case" of a "dangerous disease" go to the new system instead of redounding to the glory of Dr. Shyster, as he planned it would.

Is it any wonder true physicians sometimes get disgusted with their profession when they see a shyster come into the town where they have worked for years, patiently and conscientiously building up a legitimate practice that begins to promise a decent living, and by such quack methods as diagnosing cases of simple fever, such as might come from acute indigestion or too much play in children, as something dangerous, typhoid or "threatened typhoid," or cases of congestion of the lungs as "lung fever," and by "aborting" or "curing" these terrible diseases in short order and having his patients out in a few days, jumps into fame and (financial) success at a bound? Because the typhoid (real typhoid) patients of the honest doctor lingered for weeks and sometimes died, and because frequently he lost a case of real pneumonia, he made but a poor showing in comparison with the new doctor. "He's just fresh from school, you know, from a post-graduate course in the East." Or, "He's been to the old country and _knows_ something." Just as if any physician, though he may have been out of school for many years, does not, or may not, know of all the curative agencies of demonstrated merit!

Would a medical journal fail to keep its readers posted concerning any new discovery in medicine, or helpful appliance that promises real good to the profession? Yet people speak of one doctor's superior knowledge of the best treatment of a particular disease as if that doctor had access to some mysterious source of therapeutic knowledge unknown to other physicians. It is becoming less easy to work the "dangerous diagnosis" graft than formerly, for many people are learning that certain diseases must "run their course," and that there are no medicines that have specific curative effects on them.

There is another graft now that is taking the place of the one just mentioned, to some extent at least. In the hands of a fellow with lots of nerve and little conscience it is the greatest of them all. This is the graft of the smart young fellow direct from a post-graduate course in the clinics of some great surgeon.

He comes to town with a great flourish of trumpets. Of course, he observes the ethics of the profession! The long accounts of his superior education and unusual experience with operative surgery are only legitimate items of news for the local papers. Certainly! It is only right that such an unusual doctor should have so much attention.

There is no "starving time" for him. No weary wait of years for patients to come. At one bound he leaps into fame and fortune by performing "big operations" right and left, when before his coming such cases were only occasionally found, and then taken to surgeons of known ability and experience. The reputable physician respects surgery, and would respect the bright young fellow fresh from contact with the latest approved methods who has nerve to undertake the responsibility of a dangerous operation when such an operation is really indicated. But when it comes to mutilating the human body by cutting away an appendix or an ovary because it is known that to remove them when neither they nor the victim are much diseased is a comparatively safe and very _quick_ way to get a big reputation--that is the limit of quackery. And no wonder such a man is so cordially hated by his brethren. He not always hated because he mutilates humanity so much, as because his spectacular graft in surgery is sure to be taken as proof conclusive that he is superior in all other departments of therapeutics.

And it puzzles observing laymen sometimes to know why all the successful (?) operations are considered such desirable items of news, while the cases that are not flattering in their outcome pass unmentioned.

I find most complete corroboration of my contention in the president's address, delivered before the Western Surgical and Gynecological Association at St. Louis, in 1907, by Charles W. Oviatt, M.D. This address was published in the _Journal of the American Medical Association_, and I herewith reprint it in part:

"The ambitious medical student does not usually get far into college
work before he aspires to become a surgeon. He sees in the surgical
clinics more definite and striking results than are discernible in
other branches. Without being able to judge of his own relative
fitness or whether he possesses the special aptitude so essential to
success, he decides to become a surgeon. There will always be room for
the young surgeon who, fitted by nature for the work, takes the time
and opportunity to properly prepare himself. There is more good
surgery being done to-day than ever before, and there are more good
surgeons being educated to do the work. If, however, the surgeon of
the future is to hold the high and honorable position our leaders have
held in the past, there must be some standard of qualification
established that shall protect the people against incompetency and
dishonesty in surgeons.

"That there is much that passes under the name of surgery being done
by ill-trained, incompetent men, will not be denied. What standard,
then, should be established, and what requirement should be made
before one should be permitted to do surgery? In his address as
chairman of the Section on Surgery and Anatomy of the American Medical
Association, at the Portland (1905) meeting, Dr. Maurice H. Richardson
deals with this subject in such a forceful, clear-cut way, that I take
the liberty to quote him at some length:

"'The burden of the following remarks is that those only should
practice surgery who by education in the laboratory, in the
dissecting-room, by the bedside, and at the operating-table, are
qualified, first, to make reasonably correct deductions from
subjective and objective signs; secondly, to give sound advice for
or against operations; thirdly, to perform operations skillfully
and quickly, and, fourthly, to conduct wisely the after-treatment.

"'The task before me is a serious criticism of what is going on in
every community. I do not single out any community or any man.
There is in my mind no doubt whatever that surgery is being
practiced by those who are incompetent to practice it--by those
whose education is imperfect, who lack natural aptitude, whose
environment is such that they never can gain that personal
experience which alone will really fit them for what surgery means
to-day. They are unable to make correct deductions from histories;
to predict probable events; to perform operations skillfully, or
to manage after-treatment.

"'All surgeons are liable to error, not only in diagnosis, but in
the performance of operations based on diagnosis. Such errors must
always be expected and included in the contingencies of the
practice of medicine and surgery. Doubtless many of my hearers can
recall cases of their own in which useless--or worse than
useless--operations have been performed. If, however, serious
operations are in the hands of men of large experience, such
errors will be reduced to a minimum.

"'Many physicians send patients for diagnosis and opinion as to
the advisability of operation without telling the consultant that
they themselves are to perform the operation. The diagnosis is
made and the operation perhaps recommended, when it appears that
the operation is to be in incompetent hands. His advice should be
conditional that it be carried out only by the competent. Many
operations, like the removal of the vermiform appendix in the
period of health, the removal of fibroids which are not seriously
offending, the removal of gall-stones that are not causing
symptoms, are operations of choice rather than of necessity; they
are operations which should never be advised unless they are to be
performed by men of the greatest skill. Furthermore, many
emergency operations, such as the removal of an inflamed appendix
and other operations for lesions which are not necessarily
fatal--should be forbidden and the patient left to the chances of
spontaneous recovery, if the operation proposed is to be performed
by an incompetent.

"'And is not the surgeon, appreciating his own unfitness in spite
of years of devotion, in the position to condemn those who lightly
take up such burdens without preparation and too often without
conscience?

"'In view of these facts, who should perform surgery? How shall
the surgeon be best fitted for these grave duties? As a matter of
right and wrong, who shall, in the opinion of the medical
profession, advise and perform these responsible acts and who
shall not? Surgical operations should be performed only by those
who are educated for that special purpose.

"'I have no hesitation in saying that the proper fitting of a man
for surgical practice requires a much longer experience as a
student and assistant than the most exacting schools demand. A man
should serve four, five or six years as assistant to an active
surgeon. During this period of preparation, as it were, as much
time as possible should be given to observing the work of the
masters of surgery throughout the world.'

"While Dr. Richardson's ideal may seem almost utopian, there being so
wide a difference between the standard he would erect and the one
generally established, we must all agree that however impossible of
attainment under present conditions, such an ideal is none too high
and its future realization not too much to hope for.

"While there is being done enough poor surgery that is honest and well
intended, there is much being done that is useless, conscienceless,
and done for purely commercial ends. This is truly a disagreeable and
painful topic and one that I would gladly pass by, did I not feel that
its importance demands some word of condemnation coming through such
representative surgical organizations as this.

"The spirit of graft that has pervaded our ranks, especially here in
the West, is doing much to lower the standard and undermine the morals
and ethics of the profession. When fee-splitting and the paying of
commissions for surgical work began to be heard of something like a
decade ago, it seemed so palpably dishonest and wrong that it was
believed that it would soon die out, or be at least confined to the
few in whom the inherited commercial instinct was so strong that they
could not get away from it. But it did not die; on the other hand, it
has grown and flourished.

"In looking for an explanation for the existence of this evil, I think
several factors must be taken into account, among them being certain
changes in our social and economic conditions. This is an age of
commercialism. We are known to the world as a nation of "dollar
chasers," where nearly everything that should contribute to right
living is sacrificed to the Moloch of money. The mad rush for wealth
which has characterized the business world, has in a way induced some
medical men, whether rightfully or wrongfully, to adopt the same
measures in self-protection. The patient or his friends too often
insist on measuring the value of our services with a commercial
yard-stick, the fee to be paid being the chief consideration. In this
way the public must come in for its share of responsibility for
existing conditions. So long as there are people who care so little
who operates on them, just so long will there be cheap surgeons, cheap
in every respect, to supply the demand. The demand for better
physicians and surgeons must come in part from those who employ their
services.

"Another source of the graft evil is the existence of low-grade,
irregular and stock-company medical schools. In many of these schools
the entrance requirements are not in evidence outside of their
catalogues. With no standard of character or ethics, these schools
turn out men who have gotten the little learning they possess in the
very atmosphere of graft. The existence of these schools seems less
excusable when we consider that our leading medical colleges rank with
the best in the world and are ample for the needs of all who should
enter the profession. Their constant aim is to still further elevate
the standard and to admit as students only those who give unmistakable
evidence of being morally and intellectually fit to become members of
the profession.

"Enough men of character, however, are entering the field through
these better schools to ensure the upholding of those lofty ideals
that have characterized the profession in the past and which are
essential to our continued progress. I think, therefore, that we may
take a hopeful view of the future. The demand for better prepared
physicians will eventually close many avenues that are now open to
students, greatly to the benefit of all. With the curtailing of the
number of students and a less fierce competition which this will
bring, there will be less temptation, less necessity, if you will, on
the part of general practitioners to ask for a division of fees. He
will come to see that honest dealing on his part with the patient
requiring special skill will in the long run be the best policy. He
will make a just, open charge for the services he has rendered and not
attempt to collect a surreptitious fee through a dishonest surgeon for
services he has not rendered and could not render. Then, too, there
will be less inducement and less opportunity for incompetent and
conscienceless men to disgrace the art of surgery.

"The public mind is becoming especially active just at this time in
combating graft in all forms, and is ready to aid in its destruction.
The intelligent portion of the laity is becoming alive to the patent
medicine evil. It is only a question of time when the people will
demand that the secular papers which go into our homes shall not
contain the vile, disgusting and suggestive quack advertisements that
are found to-day. A campaign of reform is being instituted against
dishonest politicians, financiers, railroad and insurance magnates,
showing that their methods will be no longer tolerated. The moral
standards set for professional men and men in public life are going to
be higher in the future, and with the limelight of public opinion
turned on the medical and surgical grafter, the evil will cease to
exist. Hand in hand with this reform let us hope that there will come
to be established a legal and moral standard of qualification for
those who assume to do surgery.

"I feel sure that it is the wish of every member of this association
to do everything possible to hasten the coming of this day and to aid
in the uplifting of the art of surgery. Our individual effort in this
direction must lie largely through the influence we exert over those
who seek our advice before beginning the study of medicine, and over
those who, having entered the work, are to follow in our immediate
footsteps. To the young man who seeks our counsel as to the
advisability of commencing the study of medicine, it is our duty to
make a plain statement of what would be expected of him, of the cost
in time and money, and an estimate of what he might reasonably expect
as a reward for a life devoted to ceaseless study, toil and
responsibility. If, from our knowledge of the character, attainments
and qualifications of the young man we feel that at best he could make
but a modicum of success in the work, we should endeavor to divert his
ambition into some other channel.

"We should advise the 'expectant surgeon' in his preparation to follow
as nearly as possible the line of study suggested by Richardson. Then
I would add the advice of Senn, viz: 'To do general practice for
several years, return to laboratory work and surgical anatomy, attend
the clinics of different operators, and never cease to be a physician.
If this advice is followed there will be less unnecessary operating
done in the future than has been the case in the past.' The young man
who enters special work without having had experience as a general
practitioner, is seriously handicapped. In this age, when we have so
frequently to deal with the so-called border-line cases, it is
especially well never to cease being a physician.

"We would next have the young man assure himself that he is the
possessor of a well-developed, healthy, working 'surgical conscience.'
No matter how well qualified he may be, his enthusiasm in the earlier
years of his work will lead him to do operations that he would refrain
from in later life. This will be especially true of malignant disease.
He knows that early and thorough radical measures alone hold out hope,
and only by repeated unsuccessful efforts will he learn to temper his
ambition by the judgment that comes of experience. Pirogoff, the noted
surgeon, suffered from a malignant growth. Billroth refused to operate
or advise operation. In writing to another surgeon friend he said: 'I
am not the bold operator whom you knew years ago in Zurich. Before
deciding on the necessity of an operation, I always propose to myself
this question: Would you permit such an operation as you intend
performing on your patient to be done on yourself? Years and
experience bring in their train a certain degree of hesitancy.' This,
coming from one who in his day was the most brilliant operator in the
world, should be remembered by every surgeon, young and old."

Oh, surgery! Modern aseptic surgery! In the hands of the skilled, conscientious surgeon how great are thy powers for good to suffering humanity! In the hands of shysters "what crimes are committed in thy name!"

With his own school full of shysters and incompetents, and grafters of "new schools" and "systems" to compete with on every hand, the conscientious physician seems to be "between the devil and the deep sea!"

With quacks to the right of him, quacks to the left of him, quacks in front of him, all volleying and thundering with their literature to prove that the old schools, and all schools other than theirs, are frauds, impostors and poisoners, about all that is left for the layman to do when sick is to take to the woods.