Medical chaos and crime

Contents

. Tue Reten or “ Grarr”

. “ Eruics,” ReaL aND CRIMINAL

. EpucaTIoNn aT THE Cost or Human LIFE . Tue UNSPEAKABLE QUACK

Chapter I Graft ”’

THE REIGN OF “© Always seek your own interests, make of a high and sacred calling a sordid business, regard your fellow-creatures as so many tools of trade, and if your heart’s desire is for riches, they may be yours; but you will have bartered away the birthright of a noble heritage, traduced the physician’s well-deserved title of the Friend of Man, and falsified the best traditions of an ancient and honorable Guild.”—Dr. William Osler, in ** A¢quanimitas and Other Addresses.”

One would think that those who are especially fitted by training and education to treat the sick and injured, and to relieve suffering, would have developed in them to a high degree the divine qualities of sympathy and compassion. Unfortunately our ideals and practices have undergone marked changes of late, and the medical profession has by no means escaped the mercenary blight that has fastened. itself upon the nation. To be absolutely fair, I will except the rank and file who are removed from the larger cities, though urban greed and

“ oraft ” is fast spreading to the remotest hamlet. But I fearlessly assert that the leading surgeons and practitioners of the cities are no longer the men of exalted aims and scrupulous honor that formerly ennobled our profession. A valiant minority, true disciples of Atsculapius, are employing the wonderful agents that modern science has given us to true humanitarian ends, but to the majority they have become but the instruments of self-aggrandizement.

In all our great business centres the main idea in nearly every trade and profession is to make money— big money—not after the honest and leisurely manner of our fathers, but in the frantic, get-rich-quick fashion of the Twentieth Century. It is in the air, this mad desire for unearned riches, and its baneful influence is already sapping the vitality of the nation. Even now the handwriting is on the wall, though unnoticed and unread by the frenzied mob who are struggling to reach the goal of wealth. I refer to the appalling increase of crime, insanity and suicide during the last decade. If our people do not pause in this wild career we shall soon—I mean we of the cities—become a race of neurasthenics and degenerates. And the members of the medico-surgical profession are no exception. It is no longer the call of the suffering that inspires them, but the call of the dollar. They who should by precept and example strive to bring the nation to its senses are themselves in the thick of the scramble. Ethics have been undermined, principles pigeon-holed, ideals suppressed or reduced to a business basis.

The average doctor, in short, hasn’t time to think of the real things of life. He knows theoretically, just as every intelligent man knows, that wealth, instead of

THE REIGN OF —GRAPT 19 promoting peace of mind, in nine cases out of ten undermines all happiness. The possession of ten thousand dollars leads to the desire for a hundred thousand, and a hundred thousand immediately suggests a million. Or perhaps the ownership of a store or factory creates an obsession for monopoly, and so the game must be played to the limit no matter what ideals have to be sacrificed. Thus with such over-ambitious natures, each added possession but adds to his voracity ; realization brings only a new discontent, and again he sets out after a transformed and yet more elusive willo’-the-wisp.

There is a tremendous satisfaction in life if we could only keep the fact before us, in performing well each duty that presents itself. It may be a remarkable feat (of courage or skill or cunning or what not) to make a million dollars, but there is less honest satisfaction in it than that which comes from the saving of one life. Yet so false have become our standards that many a physician, formerly honest and even altruistic, has come to look upon the relief of suffering or the saving of a life as merely incidental to the earning of a fat fee. And from honest greed, if there is such a thing, the step is but a short one to dishonorable practices and deceit. Like all who have lapsed into rank commercialism, he finds that he must employ unfair means if he would achieve the success that he craves.

What a pity that we are losing those great-hearted physicians of the old school—the Doctor McClure type as depicted by Ian Maclaren! But the spirit of the age will not tolerate them. Success, no longer a gauge of character, must be measured in dollars!

“‘ It is not too much to say,” writes Dr. C. W. Lillie (of East St. Louis),’ “that more is expected of the doctor, and in the final accounting more will be required of him, because of his superior knowledge. It is also true that many doctors are so engrossed in money-making schemes, with fads and specialties in medicine, with fast horses, with automobiles, with women, wine and other dissipations, that patients have but slight consideration; that efforts directed toward the general betterment of mankind have but a small share of their attention.”

Doctor Lillie hastens to add that he absolves the large majority of doctors from such a_ sweeping charge, but so do many others who write in a similar vein, and their denunciation sounds so frank and spontaneous and the added qualifications usually so stereotyped and perfunctory that one wonders if the man has not spoken only to be suppressed by the cautious physician or scientist. In some cases the former comes off victorious, but in still others the paper or address is the interesting record of an evenly matched contest between the two, honors to be decided by the tone of the final paragraph!

Such, in a measure, is the address of Dr. L. Emmett Holt, Professor of Diseases of Children in the New York College of Physicians and Surgeons (Columbia University), which he delivered before the students on September 26, 1907.2. In the following para-

*From “Duties and Obligations Relating to Tuberculosis.” —The Illinois Medical Journal, January 19, 1907.

* Professor Holt’s paper was entitled “Medical Tendencies and Ideals,” and was reproduced in the Journal of the American Medical Association, March 9, 1907.

graph, for instance, the professional man has the upper hand :—

“Two years ago I was in attendance with another physician on the young child of a wealthy merchant, who was seriously ill and over whom was hanging the possible necessity of a grave surgical operation. The parents were naturally very anxious. When, after one of our consultations, the surgeon had left the house, the father said, ‘Do you think that man’s judgment in deciding to operate woula be influenced by the fee he would receive for it?’ Happily, in this instance, I could say, ‘ Emphatically, no.’ Nor do I believe there are many men in the profession of whom it would be true. But this anxious parent expressed a distrust which many others have felt. Conceive, if you can, a condition of society in which such a feeling of suspicion should be general, or worse still, when it should be justified. What technical skill can ever take the place of moral character in a physician or surgeon? High ethical standards have been maintained in the past by the great body of physicians to a remarkable degree, often in the face of great temptation. Let us hope that the ideals of the physicians of the future may be just as high.”

Then the man speaks out :—

“There is one other phase of commercialism seen in our day, which may be characterized as medical graft. This man does not conceal the fact that he is in medicine for what he can get out of it. With respect to every transaction he adopts the politician’s anxious query, ‘Where do I come in?’ His methods are well known. He visits the specialist, the surgeon, or consultant, ostensibly in behalf of his patient, and lets it be known that he expects ‘ the usual percentage ’ of the fee in case the patient can be persuaded, intimating at the same time that if this is made satisfactory he will need consultations in the case of other patients, and has other work which he can turn over to the surgeon.”

Now the professional man once more :—

“ Medical grafters of this type, I am glad to say, are not numerous, but they are, I must believe from my information, increasing rather rapidly. Such a man may not be at heart dishonest. Let us try to follow his mode of reasoning. He begins by contrasting his own small fees and modest income with those currently reported of the specialist or surgeon. ‘ Why should I not receive a suitable commission for the business I can control? There are plenty of skilful men who are willing to divide their fee with me. The patient is well served. Who, then, can complain? ’ ”

Whereupon the man, waxing indignant, interrupts -—

** Such a man belongs in business, not in a profession. He regards the patient as something in which he has personal or property rights, as a marketable commodity, which he is at liberty to dispose of to his own advantage.”

And so on throughout the Doctor’s most instructive address.

As stated above, however, I will confine myself for the moment to city practitioners and surgeons, and endeavor to show to what degree they have been affected by the reign of “ graft.” But the sad recital will not end with this chapter; underlying many, perhaps the major portion, of the abuses exposed in the succeeding chapters will be found this insatiable mania for unearned wealth, unearned honors, undeserved reward.

Of course, it is absurd to assume, as so many do, that ideal conditions once obtained universally in this or any other profession. Just by accident the other day, I ran across a “ dissertation” by Dr. Worthington Hooker which was read before the annual meeting of the Connecticut Medical Society, May 8, 1844. Doctor Hooker’s theme was ‘‘ The Respect Due to the Medical Profession and the Reasons that it is Not Awarded by the Community.” It is a “ muck-raking ” article, in its way, and contains some very plain language. On page 16, we read:—

** The science of patient-getting is often more assiduously studied than that of patient-curing. Real success is not so much desired as the mere appearance of it. Common ground is taken with the charlatan. The people are to be imbued with a great sense of the physician’s skill without any reference to real merit. The object is to be attained at any rate, and whether it can be done on true or false grounds seems not to be material.”

Nor are we to suppose that England or the Continent is free from these evils. It is only a few years since the death of Roose, one of the greatest charlatans who ever plied his trade; and not a few of England’s best-known practitioners will go down in history as clever ‘‘ grafters.” But this book deals with conditions to-day, and in our own country, and references to the past and to foreign countries will be made for comparison only.

No doubt there are thousands of struggling doctors who, if they could be prevailed upon to tell the truth, would admit the deceits and petty frauds that they practise on their patients, but would plead pecuniary embarrassment or downright poverty as an excuse. In the summer months, for instance, an ordinarily good practice often dwindles down to almost nothing, yet the rent and living expenses go on just the same. The worried doctor, with wits sharpened and conscience dulled, looks about him for relief, and then it is that the unwary patient is advised to undergo an operation or receives a long course of treatment.

‘The tonsils must come out!’’ A familiar remark, is it not? Furthermore, it is much better to operate in June or July (if you can hold your patient) than in the winter or early spring when business is brisk. ‘Yes, Madam, the warm weather is the time to operate on the tonsils—wounds heal more rapidly in the summer time.” Poor mothers, they are so easy to convince and so anxious to do the best for their little ones !

What a cowardly and contemptible business this is when we look into it—to deceive the loving parents and ignore the needs of the children just to relieve a depleted pocketbook! Yet it is constantly being done. Who ever hears such advice in the free clinics? There the present is always the time to operate, and sorry would be the plight of the children of the poor if only summer operations were successful. But with the private patients it pays to delay, and, furthermore, it adds to one’s reputation. For paradoxical as it may seem, the patient who is faked is the patient who is grateful. The modern practitioner’s chief asset, in short, is not his knowledge of medicine, but his ability to convince people. Whether right or wrong, if he can impress his patients he may feel sure of success, but if he cannot he might as well throw up his practice.

Inability to read the patient’s thoughts, moreover, makes a poor outlook, whereas a thorough and intuitive grasp of their methods of reasoning almost invariably presages success. In a word, to coincide with your patients’ ideas, whether right or wrong, is highly politic, and to oppose them in nine cases out of ten means simple disaster.

A well-known physician, an acquaintance of mine, practising in New York City, whose reputation is of the best, told me recently that his great success in medicine was not due to any unusual skill or knowledge, but to the fact that he was “a damned good business man and knew when to take advantage of the other fellow’s ignorance.” After further investigation of my friend and his methods, I discovered that he was rated so highly simply because he could cure the ills he personally caused. For a patient to consult him and get away without having to return is almost unheard of. His first diagnosis when he finds that the patient is a drivelling hypochondriac is “ stomach trouble,” ‘ gastric catarrh,” “ gastralgia,” or some other reverberating name, which means nothing in particular, but greatly impresses the patient. His first treatment in such a case, almost without exception, is to administer to this poor creature large and repeated doses of potassium iodide in some form, with instructions to return if he feels nausea, headache, pain, or a bad taste in the mouth.

Now it happens that potassium iodide, given in large and repeated doses and taken with a small quantity of water, causes these exact symptoms, viz., nausea, headache, pain in the stomach and a bad-tasting mouth. Consequently the dupe goes back for relief, financial and otherwise, and so the iodide is gradually reduced, while the pocketbook is being relieved of its contents. In the course of the second or third week the poor, frail, shadow of a patient wanders into the office once more. My friend now takes pity upon him by withdrawing all of the iodide, thus effecting a brilliant cure of the disease with the high-sounding name. The delighted patient, naturally, is most grateful. Having other friends afflicted with stomach trouble, he tells them of the clever doctor who has dragged him from the jaws of death. They, too, flock to the master physician, and of course are eventually ‘ cured,” the time in each case depending on the limit of patience and the extent of the bank account.

This is a case of vulgar, though highly systematized, fraud. The following, related by Dr. W. F. Manton (of Detroit)’ illustrates the callous indifference shown to the poor :—

“A patient, pregnant about the fifth month, was brought into one of our hospitals in a moribund condition. She was young and vigorous, and, save some slight bladder irritation, had been well up till the morning of the day when convulsions set in. Dilation of the os had begun, and at the hospital evacuation of the uterus was readily accomplished. The patient did not, however, regain consciousness, and died a few hours later, in spite of the most energetic efforts to save her life. The urine of the patient had not been examined

"From “The Relation of the Physician to His Pregnant Patient.”"—The Canadian Practitioner and Review, December, 1906.

THE REIGN OF “GRAFT” Q7 prior to her entrance at the hospital, and in conversation with her physician the remark was made that it still appeared necessary for the general practitioner to learn that the urine should be tested from the beginning of pregnancy, to which the doctor replied, ‘ Doctor, it does not pay.’

“The case is a pathetic illustration of the present status of obstetric practice. Here was a young woman of the poorer class, in robust health, whose life was sacrificed on account of her inability to adequately reimburse the physician for the time and skill which he might expend in caring for and directing her during the period of gestation. Unfortunately the case is not exceptional, nor is the physician to be held wholly blameworthy for following a course which is almost universally practised among patients in all stations of life.”

The next case, related to me by Doctor H. of New York, illustrates the shameless greed too often associated with deathbed consultations. ‘* I went into a small cigar store, the other day,” remarked H., “ and was roundly abused by the proprietor when he found I was a doctor. I asked him what he meant, and he told me that his wife had recently died, and that the family doctor had insisted on calling in six specialists for consultation.

““* He called those men in,’ said the poor fellow, ‘and all the money I had in the world was eleven hundred dollars. The first demanded three hundred dollars, and the rest of them got the balance. They were called in and paid within twenty-four hours, and at the end of that time my wife was dead and I was obliged to borrow money to bury her.’ ”

This seems almost incredible, but Doctor H. made enquiries and found the man’s story to be substantially correct. The family doctor, of course, had received a commission on all the fees collected, in addition to his own bill.

No less reprehensible, though more frankly brutal, was the conduct of the noted surgeon in the following case of appendicitis, which I select from scores of similar instances because of the unusually high reputation of the hero thereof :—

Mr. and Mrs. K. were a young Chicago couple just beginning to get a start in the world. Their little home was partly paid for. Only a thousand dollars was needed to clear off the mortgage, and this they had succeeded in getting together, by dint of much saving and self-denial, when the wife suddenly developed an acute attack of appendicitis. Her husband was greatly alarmed, and made enquiries as to who was the best surgeon in Chicago. He was recommended to one of the best surgeons in the country, whom we will call Doctor Y. So he rushed to the doctor’s office and begged him to come at once to see his wife. Doctor Y. said he would come without delay, and the young husband hurried home to await his arrival.

Meanwhile, Doctor Y. made enquiries over the telephone as to K.’s financial condition, and soon found out about the thousand dollars in the bank. With this information, he visited and examined Mrs. K. ‘The case was one of acute (catarrhal) appendicitis, as he had conjectured from the somewhat incoherent description of the husband. Turning to the latter, he said in his very forceful and emphatic manner :—

“This is a bad case of appendicitis; if she is not operated on at once, she will die.”

THE REIGN. OF “GRAET” 29

The reader can imagine the consternation that ensued. Of course the husband implored the doctor to do everything possible to save his dear one’s life. This was the psychological moment, as Doctor Y. well knew. So he replied, brusquely :—

“ All right, Mr. K., the operation will cost one thousand dollars, and I must have the money before I “begin.”

Poor K. gasped. He knew that great surgeons do not ordinarily operate for mere glory or gratitude, but he had never expected anything like this. His struggle was short, however, for he loved his wife. Doctor Y. was the best surgeon in Chicago, and Mrs. K. should have his services as long as he could foot the bill. So with a sigh of regret as he thought of the home passing from them, and of the years of hard struggle to come, he agreed to the doctor’s rapacious fee. Doctor Y. came again that evening with his assistants, and performed the operation, and performed it well. It was all over in less than twenty minutes, and when he left the house he carried Mr. K.’s hard-earned savings.

Doctor Y. is unquestionably a great surgeon. His skill and fame have brought him cases from all over the country, and he is a wealthy man. He did not need this thousand dollars; it meant almost less to him than a dollar meant to the poor clerk. How much manlier it would have been to have offered to take the patient to his clinic and operate on her free of charge, or else to have performed the operation at the house for a nominal fee of, say, a hundred dollars! But that would not have been “ good business,” and personal sacrifices, unless of a spectacular character, do not often appeal to the rich and famous.

It must have been the knowledge of such cases as this that led Dr. George F. Butler’ (of Wilmette,

Illinois) to write :—

“The ‘ commercialism ’ of treating a patient unnecessarily, of taking advantage of his misfortune to frighten him into being treated indefinitely or operated on unnecessarily for the sole purpose of extracting a little more money from him, is not ‘ business °—it is downright dishonesty. The physician who prostitutes his profession by frightening and then literally robbing the sick is a more contemptible robber than the ‘ footpad.’ ”

Similar incidents must have come to the notice of a certain New England clergyman who was recently provoked into exclaiming :—

“It is not a profession, it is a trade that the doctors ply to-day. It is not the practitioner of a profession who goes into a household and demands his fee of five hundred or a thousand dollars before he will apply his knife to the cancer, the anesthetic to the wound. Such practices ought to be condemned from every pulpit— every rostrum in the land. The government ought to step in and prevent them.”

Dr. A. Stuart M. Chisholm (of Bennington, Vermont), to whom this gentleman’s ideas of administering anesthetics afford no little amusement, regards such attacks as unwarranted and malicious, and attempts to prove by illustrious examples both from history and fiction, that because medicine has produced men of the noblest and most self-sacrificing type, the profession to-day must, of necessity, have preserved its ideals.

*“Commercialism in Medicine.” From the American Journal of Clinical Medicine, March, 1910.

“The study of medicine,” he informs his assembled confréres,! “is an entrancing subject, its practice requires an array of virtues whose mere contemplation staggers the mind. One must meet violence with gentleness, ingratitude with equanimity, insult with fortitude, slander with silence. The physician’s life is a daily exemplification of the Golden Rule.”

Dr. A. J. Charlton, (of Bennett, Iowa) goes Doctor Chisholm one better, in a letter to the Journal of the American Medical Association (April 4, 1908), in which he replied with more heat than argument to the attack of Mr. Bok, of the Ladies’ Home Journal, upon practitioners who, through ignorance or for profit, prescribe nostrums and proprietary remedies of uncertain composition. ‘’The<medical profession,” exclaims this irate Westerner, “is an institution devoted to the spiritual, mental and physical condition of the people, therefore all but holy.” And in conclusion :—

“It is little wonder that the public is nonplussed as to a course of action when the leading publications of our day approach them with the gravest kind of accusations against the noblest and best of our professional men, the average physician. Happily, however, the inaccuracy of these accusations is real to any layman who may stop to think, and the horror of the unsubstantiated charge is being largely replaced by a new and everlasting confidence in the members of the profession who have so patiently and painstakingly served the people. . ..”

In reply, the editor of the Journal of the A. M. A.

*“ On the Inherent Spirit of Medicine.” A paper read before the Medical Association of Troy and vicinity and published in the Albany Medical Annals, August, 1908.

points out that unfortunately Mr. Bok’s accusations are only too true. ‘“ The letter quoted above,” he states, “Sis the only communication we have received expressing disapprobation of Mr. Bok’s paper and of its publication.” And he adds :—

“The time has passed when we can wrap ourselves in a cloak of professional dignity and assume an attitude of infallibility toward the public. The more intelligent of the laity have opinions on medical subjects—often bizarre, it must be admitted, but frequently well grounded—and a fair discussion of such opinions can result only in a greater measure of confidence in, and respect for, the medical profession.”

Before returning to my narrative I cannot resist quoting the testimony of another Westerner, Dr. Charles W. Oviatt, of Oshkosh, Wisconsin, the President of the Western Surgical and Gynecological Association. In his address delivered before this association at St. Louis, December 30, 1907, Doctor Oviatt said :—

“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 at least be 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.”

Here, the reader will note, there is no hedging or supplementary qualification, and scores of outspoken practitioners and surgeons might be quoted to the same effect.' I prefer, however, to give further concrete cases, examples of heartlessness and “ graft” which, if not of every-dxy occurrence, could easily be duplicated by any doctor—any city doctor, I suppose I must say—in the land. This, of course, will be contradicted by all who are guilty of dishonest practices, as well as by those self-deluded members of the profession, who think, like our friend of Bennett, Iowa, that loudly to deny the present tendency will by some strange process restore us to the “all but holy ” state from which we have fallen.

When a young graduate in medicine hangs out his sign in a large city he must not expect, as a rule, to make his expenses for at least a year. Sometimes, however, fortune provides an early opportunity for him to distinguish himself. Such a chance befell a certain young physician in New York a number of years ago. He had been practising only a short time —that is to say, he had taken an office and displayed his sign,—when it happened, one day, that being the only doctor available he was called by a rich family to attend a young woman for some abdominal complaint. The young doctor soon found that the trouble was insignificant, but he felt that to release his hold on such a case so quickly would not be good business. Accordingly, he looked grave, and after a prolonged examination, anounced that the patient was really in a very serious condition which required immediate operation. As he was a good talker and possessed unlimited ** cheek,”’ he succeeded in winning the confidence

*See Appendix F, and note remarks of Dr. Channing W. Barrett in Appendix G.

of both patient and family, and soon secured their consent to an operation. He lost no time in performing it, sewed up the wound, and, after a period of after-treatment, sent in a bill for two thousand dollars. The exorbitant charge was paid without a murmur. The grateful family were made to believe that this able and prompt young surgeon had saved their dear one’s life, and for such a service no price that they were able to pay was too high.

Before the patient had quite recovered, however, the shrewd surgeon discovered a complication that demanded another immediate operation. Having gained the complete confidence of the unsuspecting family by his first remarkable success, his word was now law in that household. A second operation was performed, and a second bill for two thousand dollars duly honored. Then finding the game so easy, he played it for all there was in it. It seems incredible, but he actually succeeded in inducing that poor, rich victim to undergo another abdominal operation at the same modest figure.

Whether the family became disillusioned after the third operation, or whether the young surgeon feared to tempt the devil once more, I cannot say. He went abroad almost immediately afterwards, took a special course in surgery, and returned to America well equipped, both professionally and financially. He owes his start to this one case which he handled (or rather mishandled) with such consummate effrontery.