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One Man's Medicine
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Aesculapius and
Health Care 30 years ago
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Excerpts
Prologue
This prologue written in 1974 describes quite accurately the state in which we
find Health Care today.
This is a fictionalized memoir about medicine. It is true to the mood of the
thirty years it spans, during which medicine and science have abolished or
learned to control most of the old scourges, have advanced or regressed, as the
case may be, to the stage of genetic tinkering, and, in so doing, have imposed
their own unique stresses on society.
As we struggle to attain a higher plane of social organization, the
physician becomes increasingly subordinate to organizations, governments,
institutions, and men of neither license nor tradition in medicine, who have
vaulted into positions of power in the newly created health syndicate;
businessmen, lawyers, accountants, car salesmen, bankers and the new breed, the
hospital administrator: paper doctors who treat paper. They see to the health of
the by-laws, procedure manuals, bills, accounts, debits and insurance forms,
beguiled by the delusion that if the records are neat and orderly, institutional
care of the patient is neat and orderly.
The doctor, as their hireling, is forced to use the tools and services they
provide, which may not be the best available; urged to consider the community as
a whole when treating his patient; coerced into violating the confidentiality of
the doctor-patient relationship by monitoring the utilization of hospital beds
by his colleagues.
Nurses resent being "handmaidens" to the doctor, and strive to become an
independent profession.
There is a hue and cry for doctors to divest themselves of the elite position
they have held so long in medicine. Who, then, should be the elite?
Clearly the precious bond that exists between a patient and his doctor is
being riven by unqualified intruders with unlimited power. The physician, in his
spiritual and serving role, may be the commodity that is squandered in this
struggle.
The medical profession is increasingly in bondage. Like the point of an
inverted pyramid it is being pressed deeper into the ground by the weight of an
enlarging, expensive bureaucracy. If the profession of medicine is shattered by
this burden, would it be asking too much for Aesculapius to be reborn?
From Chapter 4
The interns in new starched whites gathered in the auditorium.
Shoulder-buttoned white cossack blouses draped over the belt line of starched
white pants. These were covered by short single-breasted coats starched to
cardboard consistency. We had drawn uniforms from the laundry that morning-two
uniforms, as specified in the contract. We would supply our white socks and
underwear, but the hospital would launder them in conjunction with our uniforms.
After each month of service we would pick up our paychecks. "$12.50" typed under
the Great Seal of the City. Small private hospitals paid more in a month than
the $150, plus room and board, that we would receive in a year, but they weren't
The County. The County was legend. Every city has its County.
A doctor traveling in a foreign land, mute in the language of strangers, and
deaf to the syntactical babel wrought by distance, would find instant sanctuary
in any of the Counties of the world.
The stench alone would be like the aroma of a friendly kitchen, the grimy
halls with their traffic of stretchers, the wards lined by white enameled beds,
the single beam of sunlight probing these dingy rooms like a linear halo, all
this a familiar chapel to a medical stranger in a distant land.
These hospitals are the funnels for the misery of the teeming cities; baskets
collecting the mutilations dispatched by the guillotine of tragic events. Their
admitting wards are bloody concentrations of fractures, stab wounds, bullet
holes and coma; a colloquy of cries, moans, vituperations, gurgling breath
sounds and the giggles of drunks. Young Jesuits scurrying to comfort the sick or
pray for the dying, cops assigned to guard the criminals, eager crew-cut heroes
from the district attorney's office, competed with doctors and nurses to be the
first at the bedside. Clinical material was the living legend of The County. One
year of County experience taught more than thrice the time in a private
hospital, in return for which a 90 percent loss of salary seemed a fair
equation.
In the auditorium a group of eminent doctors sat in a semi-circle on the
stage. A microphone was centrally placed. The audience in unsoiled whites was
like a layer of virgin snow in the age-stained hall. The reverse of graduation,
which dispatched us, this convocation welcomed us into the world of medicine.
Seated on the stage, his black hair sprinkled with gray, his gray mustache
sprinkled with black, hands folded across his ample belly, cheeks puffing
slightly with each breath and with twin shafts of light ricocheting from his
highly polished glasses, was S. Q. Lapius, M.D. That was how he signed his
editorials as editor of the Annals of Medicine. But as Medical Director
of The County, we learned, to avoid confusion, to think of him as Lapius. Except
for Lapius, each of the other doctors on the stage wore long white coats, some
with stethoscopes protruding from the pockets, each with a pencil light in the
breast pocket.
Lapius moved to the fore. There was a gradual hush.
"Gentlemen, my name is Simon Quentin Lapius, and as Medical Director I want
to welcome you to The County. You are privileged to be here, and we look forward
to teaching and training you for the many productive years ahead. Your
predecessors have fanned out into communities all over the nation and, by their
prowess in medicine and success in its many specialties have enhanced our
reputation as a training ground for young doctors. You will be proud to have
trained at The County, and no doubt, in the years ahead, we will point with
pride and boast that we trained you here. On either side of me are seated the
department heads, and I would like to introduce them to you. First, Dr. William
Pier, Chief of Medicine."
"Welcome, gentlemen. Your next years will be arduous indeed. You are entering a
profession which today has possibly just passed the crest of its popularity. It
is not ordained that doctors will always be held in high esteem. As Ambrose
Bierce said, a physician is one upon whom we set our hopes when ill and our dogs
when well. Pliny the Elder was scathing in his criticisms of doctors, a trend
reversed briefly by the triumphs of Galen. But in the sixteenth century the docs
were in the trough again simply because they couldn't fool all the sick all of
the time. It is recorded that Louis XIII of France in a single year took 288
purges, 224 enemas and was bled on 42 occasions, which may have prompted
Montaigne to say, 'I notice no man as soon sick or as late cured as the one who
persists in a physician's care.' But medicine was rescued by the brilliant
advances of the seventeenth, eighteenth and nineteenth centuries, prompting
Whittier to cast the doctor in the hero's role:
Smite down the dragons fell and strong,
Whose breath is fever fire;
No knight of fable or of song
Encountered foes more dire.
Finally Martin Arrowsmith became legend, and there is no
doubt in my mind that at least some of you in this audience were inspired to go
into medicine after reading his famous story. Well, there will be no heroes at
The County. It's just work and more work. Exhausting hours. You will lose more
patients than you save. You will, I hope, become humble men, because here you
will be tested in the service of medicine, and when you leave you will have
learned what it takes to be a doctor, and to earn the respect of the community."
He sat down abruptly. "That's my kind of doctor," . . .
From Chapter 7
Down sex, up sciences. I entered a celibate life of discovery. The project
involved feeding to rats cancer-producing agents which caused breast cancers and
a few leukemias to grow. Bianca Fiore was the main line of communication between
Crow and the rats, the ferret who noted every shiver and chill in the animals,
grew alarmed when their noses were encrusted, excited when their blood counts
jumped, and exuberant when small tumors first became palpable in the mammary
glands. It was she who first found the tumors and called them to Crow's
attention. He had been trying, logically of course, to produce stomach tumors by
putting cancer-inducing substances into the stomachs of rats. But nothing ever
grew in the stomach. But to Crow's credit, he stopped worrying about stomach
cancer and went into the breast-cancer business.
Crow told me that I was on loan to Caspar for a lecture series on
inflammation.
The next day Caspar called and told me to plan a series of lectures on
inflammation. I spent the night in the library. Who the hell was worried about
inflammation?
It turned out that a lot of people had worried about the inflammation. Aside
from those who suffered from it, there was Metchnikoff, and maybe some great
doctors before him. I read rapidly and made notes. At the first lecture, I dealt
only with the historical introduction, buying time to study the rest of the
subject. I bought one week. That was the week I met Machaon.
It seemed that almost every article in the contemporary literature on
inflammation had been written by Ari Machaon. Inflammation is clinically
characterized by four classical signs, -tumor, calor, rubor and dolor-and anyone
who has ever had a boil can translate these into swelling, heat, redness and
pain. Every time an irritant enters the body, the body responds by pouring forth
at the site a sticky broth of proteins, chemicals, cellular material and the
cells themselves, which erect chemical and physical barricades to limit the
migration of the foreign substance. Having localized the invader, cellular
mechanisms attempt to isolate and destroy it. The conflict results in
inflammation.
To Machaon the process wasn't just a "natural" response. You can say,
"Naturally if you stick your finger, it will bleed." But the reason it bleeds is
because small blood-bearing channels are disrupted. Of course if you get a
splinter, the site will become inflamed. Machaon wanted to define each chemical
signal that called forth the inflammatory response.
To determine these factors, he injected irritating substances into laboratory
animals, then collected the exudate at different stages of the development of
the abscess, and submitted the material to crude chemical and physical
fractionation. Body fluids of this sort can be separated into component parts by
a number of methods. Through heat, the protein coagulum can be separated from
the part that remains fluid. Or certain salts can be added that coagulate
different fractions of the proteins, Machaon used these methods to separate a
number of fractions of the proteins. Machaon used these methods to separate a
number of fractions of inflammatory fluids. He had labored for many years, using
little more than kitchen salt and centrifuge. He would reinject the separate
samples into laboratory animals to determine which aspect of inflammation each
would incite. Some stimulated the migration of leucocytes to the site, others
caused edema, others temperature elevation. Simple. But Machaon was the guy who
did it. His papers came from Harvard, Chicago, Duke, a government agency. He'd
been all over the lot. It took most of the week to wade through his arguments,
which were comprehensive and often repetitious. But when I reached his later
papers, I was astounded to find in italics at the bottom of the title page:
"Director of the Department of Experimental Pathology, Alice Fremont Foundation
for Cancer Research, and Associate Professor of Pathology, Church Medical
School."
Philadelphia Inquirer, May 31, 1975
Not Your Most General Practitioner Reviewed by Max Spindel One Man's
Medicine by Charles Harris Harper & Row. $10.95
"A Blockbuster," Publishers Weekly calls this book. Well, not exactly. But an
excellent Arrowsmith-type story, highly disturbing in its examination of
institutionalized medicine, but highly entertaining at the same time.
These are supposed to be the "fictional memoirs" of one Dr. Harry, during
four stages of his first 30 years in medicine - county hospital, research,
community health and geriatric home. None of these comes off very well as the
author graphically portrays the triumphs and travail, the joys and jealousies,
the stench, the blood, the putrid flesh, amid the binding red tape and the
dog-eat-dog politics of hospital faculties and institution staffs.
He makes his points by means of anecdotes piled on anecdotes, most of them
sad, a few of tem funny. Which of these are fictional is hard to say. The
stories ring true, though, and the medical language- at least to a layman- is
authentic. Dr. Harris is a well-known physician, but the usually profuse black
flap gives scant background; it merely says that he spent 20 years of his career
in cancer research and clinical medicine, and is now in private practice.
"Another physician is more brother and cousin to me than kith or kin," Dr.
Harris writes. "I know what he has been through, and what he has to offer. I
know his dedication and integrity. I know his bones and his mind."
But despite these words, Dr. Harry is unsparing in his criticism of sloppy,
inefficient- yes, even venal- doctors. To him the patient comes first- "the
singular affinity that develops between doctor and patient, where authority and
responsibility are bound in a single passion to cure the sick, or, failing that,
to make the incurable comfortable and support their death with humanity and
dignity."
Dr. Harry's memoirs make it clear that he has no love for "the new breed, the
hospital administrator, paper doctors who treat paper." The physician, he fears,
has become increasingly subordinate to "organizations, governments, institutions
and men of neither license nor tradition in medicine, who have vaulted into
positions of power in the newly created health syndicate."
He is angered when the doctor is "coerced into violating the confidentiality
of the doctor-patient relationship by monitoring the utilization of hospital
beds." He is irate over the mew matriarchate of nurses who resent being
"handmaidens" to doctors and usurp their prerogatives.
"The medical profession is increasingly in bondage," he laments.
First under his verbal microscope to wind up with a dismal diagnosis are the
county hospitals, "funnels for the misery of the teeming cities, baskets
collecting the mutilations dispatched by the guillotines of tragic events. . .
My internship was a cave, a caveman."
Then, research - trying but stimulating although the moments of glory are
brief and impalpable. . . "It's like a perfect rose, for the brief exhilarating
periods of fragrant joy before the petals wither." Here the internecine battling
between the top men in the field spoiled it all for Dr. Harry. Next under the
scalpel is the community health center, where the intractable nurses finally
drove him out. "This was no clinic. It was a battalion aid station. A
redemployment center."
Finally, the nursing home, where Dr. Harry had to take his mentor, Dr. Lapius,
to die in filth. "A violent conspiracy exists between medical progress, the
institutes and illness itself, that finally robs the victim of the last vestiges
of human dignity. The dehumanization is so complete that family, friends and
ultimately the patient must conclude that death is the better alternative."
From these examples, it is obvious that Dr. Harry has a way with words - some
of them four-letter ones. The book is fast-moving, and there are even some
dollops of sex (with two love-me-and-leave-me nurses) to prove that doctors and
nurses are all too human.
It is left for one of this sex partners to reminisce about Dr. Harry's
induction into medicine - "You were a free hand in flight, so excited, so
stimulated, so provocative."
The Establishment caged the bird.
Nevertheless, Dr. Harris writes, "I love the profession of medicine, which
for 5000 years has been dedicated to the decent motivation. I am proud of the
tradition, and grateful for having been given the tools that allow me to follow
it. I hope my book will persuade the public that the orthodox center of the
profession is neither crass nor cynical. It is sacred, loving and caring -
qualities that must be preserved in whatever processes are used to bring the
best medicine has to offer to all people."
Max Spindel recently retired from the Inquirer's news staff.
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