The Physician as Custodian of the Health of the People: But Who Shall Guard the Custodian Himself?

Annual Oration 1925

By David Cheever, M.D.

Nearly a century and a half have passed since our medical forefathers conceived and brought into existence the Massachusetts Medical Society,—a period covering practically the political existence of our Commonwealth, and spanning half of the period which has elapsed since the first handful of Pilgrims and Puritans began to reclaim the wilderness and replace its aboriginal savagery with the civilization of the Old World. High-minded men were these, whose first care, after providing for food, shelter, and protection from savages, was to provide houses where God might be worshipped as their consciences dictated, and where their children might be educated. Sturdy self-reliance and the discharge of the responsibilities of each person to the community were dominating traits in these folk. Far removed from the educational currents of the Old World, they tried steadily to advance themselves in learning by reading, by establishing schools and colleges and Lyceums, and by correspondence with sympathetic spirits abroad. Doubtless it was the same passion for self-improvement which prompted the physicians of the community to attempt organization in 1766. The project fell through at first, and lay dormant during the Revolution, but was revived by many of the same group and brought to fruition in 1781 when the new Commonwealth granted its charter to our Society.

Thirty-one of these founders there were; fourteen of whom practised among the twelve thousand inhabitants of Boston, and the other sixteen were scattered through the neighboringtowns,—only two living as far west as Springfield. We know them to have been leaders in their communities,—beloved physicians, active also in civic duties, and counsellors in matters concerning public health;—true guardians, self-appointed, of the health of the people. They were united by bonds of friendship as well as of profession, and the annual meetings which have continued without interruption to the present day, were often spoken of as festivals, suggesting the joyous renewal of old companionship. Jealousies there were, no doubt, and rivalries and even personal animosities, as always there will be among vigorous men,—but these only threw into higher relief the solidity of their union.

In such a small circle those whom death had claimed were sadly missed, and for many years it was the custom of the anniversary orator to enumerate and briefly to characterize those who had died during the previous year. Too numerous are we now, with our four thousand members, to make such individual reference, but let us stop for a moment and give thought to our Fellows who have gone beyond in the year just passed; let us silently offer thanks for their high character, for their loyalty to the best traditions of our profession,—let us excuse their human failings and forget their faults, and above all let us resolve that eager hands shall grasp the torch that each laid down.

The Objects of The Society

Many times from this rostrum have your orators recalled the objects which underlay the foundation of our Society, and as often have discussed how they have been fulfilled. These objects, however multiplied and expressed, all may be reduced to the guarding of the health of the people, to be achieved by many and various means, notably by advancing medical knowledge among the members of the Society: by protection of the people against the fraud and deception practised by quacks and charlatans; by promoting the best standards of medical education; by discouraging unbecoming rivalries and jealousies among physicians; by education of the public in matters of individual and community health. We have just reason to be proud of our unselfish and fruitful efforts through these years. At first alone, and then in company of the Harvard Medical School, the Society was empowered by the State to examine into the qualifications for practice of candidates and to certify to their fitness, and later, through committees and individual members, it urged and finally secured the all too tardy passage of the medical practice licensing act. The service of its members on this Board has been limited only by the restrictions of an unwise statute whose modification we are now vigorously pressing. From the earliest days the Society has caused to be investigated epidemics and conditions menacing to public health, and has undertaken or urged upon governing bodies measures for their relief. The establishment of Boards of Health; the creation and the administration of the office of medical examiner in place of the notorious coroner system; the establishment of State hospitals for the insane, for the tuberculous, for the feeble minded; the promotion of reforms and advances in medical education, have emanated in large part from members of the Society in their individual or associated capacity. The founding of the New England Journal of Medicine and Surgery and of its successor, our present Journal; the creation and carrying on of almost every leading hospital in the State, have been the work of our Fellows. In others ways too numerous to mention have we sought to realize the objects of our being.

Some Achievements and Expectations

The word "unselfish" has been used to characterize our motives and attitude. It is not meant to be implied that no selfish aims or mercenary purposes have entered into our actions, but it is beyond denial that the tone of the activities of our Society has been altruistic to a degree shared by none other of the liberal professions save the ministry and teaching. No other group of men seek industriously to abolish the conditions which afford them daily bread. When, before the discovery of the typhoid bacillus in 1880 by Eberth, one of our former orators, Dr. Thomas H. Gage, declared his belief that typhoid fever was disseminated by the stools and other excreta of patients, and advocated their disinfection and the isolation of the sick, he took the most effective step possible to reduce his professional earnings. In succeeding years sanitary measures proposed and largely executed by physicians, and anti-typhoid vaccination devised and practised by physicians have nearly swept the disease from our communities, so that no longer can the practitioner anticipate the annual crop of patients who occupied a large part of his time and filled the pages of his day book year after year during the late summer and autumn months. When any protective inoculation or vaccination is perfected and practised, when in the course of abdominal section for various conditions, the useless and normal but potentially harmful appendix vermiformis is sought out and removed lest it later jeopardize the patient's life, the most certain means have been taken deliberately to diminish the doctor's business and income. It is true that the sphere and scope of medicine has been widened immensely by the growth of medical science, and that industrial and preventive medicine have opened new fields which require many recruits from medical ranks, but, nevertheless, it seems certain that discoveries which now tremble at the threshold of human consciousness will change the whole face of medical practice. When the ideal antiseptic shall be found, which, carried by the blood or lymph streams, can destroy infectious organisms throughout the body,—when the cause and the logically succeeding cure of cancer shall be demonstrated,—most doctors must beat their scalpels into ploughshares and their lancets into pruning hooks, for their occupation will be gone.

Some Immediate Problems

For 120 years matters which have vexed and interested this audience have been discussed at these annual meetings, and the reader who glances through the old records cannot fail to be struck by their similarity, nay, their identity, with those which confront us now. None have been permanently settled, though some have assumed a lesser significance and some new ones have been added. Let us examine some of these problems, and note their present status.

Medical education has been quite naturally a hardy perennial among these problems. At the time of our founding young men who wished to become doctors apprenticed themselves to local practitioners, went with them on their rounds, helped to prepare medicines, pills and plasters, read their often scanty libraries and, depending on the amount of leisure and conscience of the chief, discussed medical problems with him. In addition there was doubtless much salutary drudgery which occupied their spare time. There was no authority whose prescribed course or tests for fitness to practice must be met. Any person could announce himself as a doctor and begin practice. The Charter of the Society empowered it to examine candidates and certify to their fitness to practice, and to fix requirements for the admission of these licentiates to the Society itself, which however in no way inhibited outsiders from practising medicine without passing any test of their fitness. Their sole disqualifications lay in the denial by the State of their right to go to law to collect their fees. The records show how conscientiously the Society has discharged the trust thus imposed on it by the Commonwealth;—first requiring that a candidate must pass three full years assisting in the practice of a reputable practitioner before presenting himself for examination, then modifying that in consideration of a degree from the Harvard Medical School or the Berkshire Medical Institution, then prescribing the general cultural qualifications of a candidate, and finally designating a list of approved medical schools whose diploma should qualify a candidate to be examined by our Board of Censors. A potent element in the maintenance of medical standards in the State was the declaration in a by-law that those who practised without the Society's licensure must be considered as irregular practitioners with whom members must not consult or associate professionally. Finally it was due to the constant agitation on the part of the Society and its members that the Commonwealth in 1894—a date so long after similar actions elsewhere that it causes mortification, made the licensing to practice medicine a function of the State. As Burrage remarks in his "History" it was the conscientious maintaining of medical standards in the State by the Society which made the delay in the creation of a Board of Registration so relatively harmless.

Problems in education still confront the profession. Swept on with the tide of human progress, the tendency is to demand more time, more effort, more elaboration for the study of medicine. But counter currents are plainly to be seen;—the course is so long and expensive, and the preliminary requirements so high, that promising young men, who might be expected to make good doctors, are unacceptable to the medical schools, or are deterred from entering on the course. The supply of doctors is said not to be equal to the demand; the recent graduate is loath to settle in less favorable districts, and as the older generation passes its place is not filled and medical attention is sadly lacking. It is seriously urged that the standards be relaxed, that two grades of medical education be permitted, in order presumably that the less well trained physicians shall settle in the rural or least desirable regions. The proposal seems monstrous at first, but it has been eloquently advocated in influential quarters. In which scale will the Massachusetts Medical Society throw its weighty influence? Can we seriously maintain that doctors who are not well trained enough for city folks, are good enough for country people? What slightest probability is there that a relaxation of standards will induce men to adopt country practice? Surely the influence of our Society must continue to be thrown on the side of the maintenance of a high standard of medical education, rationally planned to enable him who receives it to exercise all reasonable agencies of medical science in its practice without requiring that he be trained to original research. Recent surveys seem to show that there is no general scarcity of physicians, that there are more per capita in this State than in most countries of the Old World. The problem is one of distribution, and like similar problems in other fields it cannot be solved artificially, but by natural evolutionary processes. It is likely that communities which will support decently a good doctor, and are enlightened enough to attach the proper value to his services, will not go unattended. Meanwhile the making of good roads, the development of motor transportation, perhaps the placing of well-staffed cottage hospitals at strategic points, must be depended on to prevent serious deprivation of medical services.

Specialization

Another perennial question, closely linked with education, is the effect of specialization on the community and on the doctor. Contrary to present opinion, this is not solely of recent origin. More than a hundred years ago,—in 1810 to be exact, it was hinted at by Dr. Joseph Bartlett, the orator of that year, in his dissertation on "The Progress of Medical Science in the Commonwealth of Massachusetts," when he said: "Though some individuals have been celebrated in particular branches of practice, there are no established distinctions as in other countries, the utility of which has been considered problematical." Does not this suggest that a development of practice abroad was thought with some apprehension to be threatening an invasion here? Nearly fifty years later, in 1859, it is evident that specialism is an accomplished fact, for Dr. Timothy Childs in his "Dissertation on Rational Medicine" vigorously defends its advent. Eighteen years later, but still nearly fifty years ago Dr. J. R. Bronson quoted a writer in the London Lancet as saying: "I have been recently honored by a visit from a lady of typical modern intelligence who consulted me about a fibroid tumor of the uterus, and lest I should stray beyond my business she was careful to inform me that Dr. Brown-Sequard had charge of her nervous system, that Dr. Williams attended to her lungs, that her abdominal organs were entrusted to Sir William Gull, that Mr. Spencer Wells looked after her rectum, and that Dr. Walsh had her heart. If some adventurous doctor should .... open an institution for diseases of the umbilicus, the only region still unappropriated, I think I can promise him more than one patient." Evidently then it is many years since specialization first began to agitate both doctor and layman.

Specialism has attended the vast increase which characterized every field of knowledge in the nineteenth century, in medicine in common with others. Without it the progress of the sciences and the art of their application would have been set back a hundred years. It is an integral part of the evolution of science, and as impossible to be combatted by the medical fundamentalists, as is the truth of organic evolution by William Jennings Bryan. It is unfortunate that some commentators assume that the general practitioner and the specialist are mutually incompatible, whereas in reality they are clearly complementary, and each is essential in medical practice. Is it not possible that, too many tears have been shed over the alleged disappearance of the family doctor?—first, because, as Mark Twain remarked about the report of his death, it is considerably exaggerated; and second, because it seems impossible in the nature of things that he ever will disappear. No finer type of man has existed, nor exists now, than the general practitioner. Devoted to his humane profession, tender, sympathetic, rugged to face the inclemencies of the seasons, underpaid or paid not at all, he has brought to his patients not only what help was afforded by the medical knowledge of his time, but also comfort, aid and advice in countless human problems not a part of medicine. His memory is enshrined in the traditions of our New England country-side, and the likeness of his personality and character are perpetuated in the literature of our people.

But think of his relative helplessness in the old days in the face of sickness! The self-limited diseases went on to a favorable or a fatal issue under his watchful eye, but relatively unmodified by his treatment. Much need for sympathy he had, indeed, as he sat by the bedside of the youth stricken with peri-typhlitis, and watched the dreaded peritonitis spread from the region of the cecum and appendix over the whole abdomen. He was ignorant of the true cause and helpless to modify the course of the disease except by the help afforded by opium in quieting persistalsis and allaying pain. Well might his character grow in sweetness, in compassion, in tender willingness to help bear the sorrows of others, as he cared for a child with suppuration in the middle ear, and tried to assuage the pain of the bursting drum membrane with drops and poultices, and essayed in vain to combat the septic fever with febrifuges and alteratives, while watching the suppuration spread to mastoid, to jugular vein, to meninges until fatal meningitis ended the agony. To be a family doctor in those days required the heart of a lion, the rugged stamina of a frontiersman and the intuition and sympathy of a woman. Compare the specialist today:—he is called to ease the same ear-ache; a moment's examination with the otoscope shows the bulging drum,—a few inhalations of an anaesthetic and in the ensuing sleep a small incision frees the streptococcus-laden serum to a harmless drainage into the outer canal, and prevents the threatening spread with intensified virulence to the mastoid cells. The patient sinks into a painless sleep. That is all. It has not taken fifteen minutes. Perhaps not even an after visit is necessary. There has been no especial occasion for the lavishing of sympathy. There has been no time for him to weave himself into the heart strings of the family; indeed,—man of action that he is,—he has already departed to attend another call. And yet this impersonal specialist, by his highly cultivated skill in the use of instrument of precision, has prevented suffering and perhaps saved a life where the-old doctor would have failed. How can it be said that he is anything but a blessing!

But we all know the evils that his flesh is heir to. He is sometimes justly accused of narrowness of vision, of not seeing beyond his own special field,—of treating the disease and not the patient. He may seem mercenary, but his equipment is expensive, his staff must be ample and his means of locomotion rapid and sure to enable him to meet the demand upon him. Perhaps he has divided the field into such minute areas that the bewildered layman finds that his family has been attended by a baker's dozen of specialists in order to care for the illnesses of a single season. But we must remember that to some extent this situation is forced upon the medical profession by this same layman who sees specialization about him everywhere among those who minister to his wants, and who has begun thoroughly to believe in it.

The specialist must have the training and some of the experience of the general practitioner before he retires into his own particular citadel, and thereafter he must leave open all the doors and windows, so that the outer world of medicine shall not be shut from view, and that currents and counter currents of medical thought may reach him freely. It has often been urged that he should actually engage in general practice for a number of years. This would mean the spending of years of the most creative period of his life in the watchful waiting and minor activities necessary to lay the foundation for general practice. The same end could be attained by taking a post as interne in the general medical or surgical service of a large hospital, and following this by service in a more responsible position, as resident or assistant resident, which would afford a knowledge of general medicine in more concentrated form, although it would not ensure him the experience and facility in human intercourse which can only be gained by practice outside the walls of an institution. A medical student who, on graduation, at once engages in the intensive cultivation of a specialty, condemns himself to a limited field of vision and a distorted perspective.

The General Practitioner

On the other hand, the family doctor can and should take leaves from the book of the specialist. The training given by a first rate medical school ought to enable him to carry his knowledge of special fields a little further,—far enough at least to make him independent of his brother in the average simple case. Instruments for diagnosis and treatment have been simplified and made easier for the inexpert to use;—as for instance the electrically lighted opthalmoscope, otoscope, laryngoscope and proctoscope. He should be able to recognize optic atrophy and a choked disc, to note a tympanum filled with pus and to perform paracentesis of the drum,—to view the vocal cords; to examine the interior of the lower sigmoid and rectum with the proctoscope. The tendency of all new and highly specialized diagnostic and therapeutic methods is toward simplification of the early complicated apparatus and technique, which brings them, though unattainable at first, finally within the scope of the general practitioner. The same trend characterizes some, at least, of laboratory methods of diagnosis. But, on the other hand, it should be remembered that the use of some of these methods by any but an expert sometimes leads to grave mistakes. It is easy, for instance, to make roentgenograms of the bony skeleton, and to judge correctly of most fractures, or cases of foreign bodies in the tissues, but the interpretation of X-ray studies of the alimentary tract, or of films of the lungs, by anyone but an expert often leads to erroneous conclusions and unwise treatment.

There is no more probability that the general practitioner will actually disappear than that the infantryman will cease to be the main reliance of a military establishment. He is in fact the doughboy, the poilu, the very backbone of the great army of physicians which is constantly waging warfare against disease. On his efficiency and well-being depends the morale of that army. After the daring aviators of the medical forces, the research men and laboratory workers, have mapped out the enemy's positions and threatened his lines of communication;—after those effective tanks, the specialists, have burst through the hostile lines, supported by a heavy artillery barrage of pedagogy and a lethal gas cloud of medical journalism;—after these brilliant exploits it is the general practitioner's infantry who go forward, overcome the last resistance of the enemy, mop up the trenches, dig themselves in, consolidate the hard-won positions, and hold them against hostile counter attacks. And not seldom an individual infantryman, like Edward Jenner, may conceive and carry out a manoeuvre that will scatter a whole unit of the enemy to the four winds of Heaven.

The practitioner is indispensable, but let him look to his laurels lest they be snatched by some of his showy and brilliant allies. When he leaves the medical school and hospital only the preliminary part of his education is finished. Though he shall become too busy to visit either of these institutions again, the richest part of his experience lies ahead of him in private practice. It is a mistake to suppose that scientific medicine can be practised only in great centers of population, under the shadow of well equipped laboratories. To make careful observations of the phenomena of disease, to use skilfully our five-senses and such special instruments as we can command, to reason logically to a conclusion from such data, and to apply appropriate remedies, is as truly scientific in method as the work of the laboratory research man. To attend a patient zealously for months or years, and when the fatal issue comes, to perform an autopsy and see the secrets which baffled us revealed before our eyes, affords a physician a course in clinical medicine far more profitable than one in the post-graduate school. Read a paper by John C. Warren, presented before this Society in 1809, on "Cases of Organic Disease of the Heart." It is a splendid contribution, based on ten private patients, every one of whom after the inevitable fatal issue came to autopsy. Warren says: "It is proof of an enlightened age and country that no objections were made in any instance to the examinations which have afforded us so much useful information." Would that the same could be said now! But how many of us make it a custom to try to secure autopsies on our private patients?

Quasi-Medical Cults

Let us turn to another of the things that tend to thwart us (a perplexity of a different nature),—the quasi-medical cults. To present an organized resistance against their threats aimed at the health of the people was avowedly one of the reasons for the founding of our Society. The quacks and charlatans and self-deceived proponents of purely empirical or speculative methods of treatment encumbered the earth then, as they do now without sensible diminution. Zadok Howe in 1834 said to this Society: "The general diffusion of knowledge and the boasted march of intellect of which so much has been said, seem not to have retarded the progress of quackery in the smallest degree; its course is onward;—refinements in the science of imposition keep pace with other improvements of the day, and so long as a portion of mankind must and will be imposed upon, there will always be found a set of choice spirits to contrive and point out the ways and means. Opposition to quackery from the regular practitioner is construed as persecution." Is not this as true as the day it was written? Mesmerism, Eclecticism, Thompsonianism; the Botanic, Electric and Analeptic systems; the Anapathist and Hydropathist; Spiritualism, Perkinsism, Christian Science, Mental Healing, Indian Herb Doctors, Chinese Herb Doctors, Seventh Sons, Natural Bone setters; Vitapaths, Naturopaths, Osteopaths, and Chiropractors;—this is but a partial list of the dreary crew. Many of them are now but memories of a past era of delusion, but it is a real question whether they died from inanition in a world which derived more sustenance from science and truth, or whether they were merely stifled by the ranker growth of more recently planted weeds, which, like parasites from foreign lands, grow more luxuriantly in a virgin soil. One is reminded of Swift's couplet: "A flea has smaller fleas that on him prey; and these have smaller still to bite 'em, and so proceed ad infinitum." If there is any actual diminution in the number of quacks, imposters, fraudulent "cures" and well intentioned but mistaken healers, it is certainly not evident to most of us.

It has been the fashion to ascribe a large part of the success of these quasi-medical cults to the sins of omission or commission of the regular profession, in the sense that if the latter had paid more attention to the particular ailments alleged to be cured by the former, and to their methods, there would have been no fertile soil to give them growth. Though this may be true to a limited extent, we are certainly deserving of a spirited defense against the extent of the indictment. If scientific medicine could demonstrate the specific cause for every disease, and a specific cure therefor, nevertheless, death being finally inevitable, people would still listen to the fraudulent claims of those who offer the impossible. We do not know the antiquity of man (unless indeed we are Fundamentalists), but let us suppose it is somewhere between the extremes proposed by palaeontologists, five hundred thousand or ten million years. If in even the shorter period, Homo Sapiens has advanced no farther in reasoning power, intelligence and knowledge than his present state as evinced by the credulity and willingness to be imposed upon of the people at large, it is too much to expect that the lifespan of the Massachusetts Medical Society has witnessed much change, or that our people are any less likely to worship false idols than they were at the time of its foundation. The anniversary orator of the year 2025 will in all probability address the Society on the cultists of that period. Curiously enough the facts established by modern science, and the marvels it has wrought have made it easier instead of harder to impose on the credulity of all but scientifically trained persons. We accept the fact as proved that the indivisible atom,—the ultimate component of the invisible molecule, is in reality composed of scores or hundreds of electrons which are moving with incredible speed about a central proton. We can watch a lymphoid tumor shrink to the point of disappearance, painlessly and insensibly, because a source of radiant energy has been held near it. Why then should it be incredible that thought emanations from the human brain may cause changes in diseased tissues? The fisherman on the Grand Banks, lying in his forecastle bunk, turns on the radio and listens to a musical performance on a New York stage;—the explorer on the Orinoco listens to the inaugural address of a President of the United States;—why then is it absurd to believe that a specimen of a patient's blood sent to San Francisco may be subjected to analysis by alleged electronic reaction and afford infallible diagnosis and indications for relief? The one case is susceptible of scientific proof to the trained mind and the other is not, but to the untrained the claims of the imposter appear to be expressed in as convincing a manner and to rest on as reliable authority as those of the scientist.

Active hostility to the cults does not succeed and has an unfortunate reaction. The cry of persecution by the "medical trust" goes up, the victim becomes a martyr, and there fly to his support all those forces which zealously guard their conception of democracy, and her inalienable right to commit every possible blunder without let or hindrance. It must be admitted that a man has the inherent right to try whatever treatment he will, provided that by so doing he does not endanger the health of the community. We can do no more than insist that those who make a profession of treating disease shall have studied and shall possess some knowledge of the fundamentals of medical science, hoping that this will cause them to make such selection of their cases as will at least do no harm. Any veritable success in treatment at the hands of the cultists inevitably will have influence in the practice of regular physicians, just as the favorable results of empiricism from whatever source have always been incorporated into the art of healing. The admission of new methods has often been tardy; it is chastening to remember the manner in which the announcement of his discovery of the circulation by Harvey, the introduction of inoculation by Jenner, the ausculation of Laennec, and the antiseptic method of Lister were ridiculed and denounced by many leaders of the profession.

Education, it will be said, that panacea for all the ills which Democracy is heir to, can be depended on to rid the community of the evils of quasi-medical cults. This is an age of propaganda, and from the lecture platform, the pulpit, the daily newspaper, the way-side bill board, those who have a message are assailing our senses. The very ether is charged with information about health and disease, cooking recipes, sermons, broadcasted from a thousand stations. No doubt dissemination by such means of information about medical matters does some good, but the public are surfeited with propaganda and rightfully harbor suspicion as to its disinterestedness. The true way of spreading the gospel of medical science is by personal appeal. Almost every sick individual sooner or later comes into personal contact with a regular physician. If the skill, the kindness, the disinterestedness, the obvious honesty of the doctor impress the patient,—if he will take time to answer questions, to explain in simple language the nature of the disease, its cause, its probable course, and the reasons why the treatment adopted may be expected to be effective or otherwise, and the reasons also why the claims of the charlatans are not to be believed, it will be unlikely that that particular individual will fall into their trap. Time was, and not in the legendary past, either, when physicians cloaked their wisdom in portentous silence, wrote their prescriptions in a dead language and in well-nigh undecipherable characters, and frowned upon frank statement. That day ought to have passed, but it has not—wholly. It would be incredible were it not true, that patients present themselves with abdominal scars, and in reply to questions state that they never could find out just what the surgeon did. A settled policy of obtaining the cooperation of patients by making them equal partners with the physician in undertaking measures for their relief will ensure a mutual loyalty and confidence which are likely to be lacking under other conditions. It is a pity that we as physicians so often think that we are too busy to permit a candid, unreserved discussion of the facts.

Some Delinquencies to Be Corrected

Commentators on matters medical, from Hippocrates to the present day, jealous of the reputation of the healing art, almost always bewail the lessening respect in which the profession is held, at the particular time at which they write. It always has had its detractors, its Molières and its George Bernard Shaws, whose satire, though often bitter and undeserved, has sometimes held up the mirror to our weaknesses in a way to make us wince. The present is no exception. Clear-thinking people know that, scientific medicine has today vastly more to offer to relieve sickness and disability than at any other period of history, and these same people know that there is no group in the community who represent more truly the qualities of altruism, self-sacrifice, and real devotion to a high cause than the medical fraternity. But there are ugly tendencies apparent which give opportunity to those so disposed to mock our pretensions, and to the charlatan to point to our failures while he advertises his cures. It is an unpleasant duty to drag these things out to the light of day, but dragged out they must be and exposed to public, gaze in pillory and stocks, in true New England fashion.

Diagnosis and treatment, the Alpha and Omega of medical practice, depend primarily on accurate observation, which broadly speaking includes a history, a physical examination, and possibly laboratory tests. The latter, according to their difficulty, may or may not be at the disposal of the doctor, but the first two of the triad are available to every one of us who still retains his senses and his faculties. But the fact is that a physical examination is often totally omitted by the physician, who nevertheless undertakes to prescribe and direct treatment and accepts a fee for so doing. This is a serious indictment;—let us justify it by a definite, specific example. In the period from 1920 to the present 16 patients with carcinoma of the lower bowel have come under observation. Not one of them could be classed as in an early stage. Every one of them had applied to a physician, complaining of pain or bleeding or obstruction, or seeking relief from what they considered to be haemorrhoids. In exactly 4 of these cases did the physician make an examination to determine the diagnosis. In some instances numerous office visits were made, in one case three physicians were consulted in turn before an examination was done. It is true that an instrument of precision was necessary,—the most perfect, the most complex, the most infallible ever devised, but one with which every physician is provided and the technical use of which he is well skilled in. It is the right index finger! In every case a plainly to-be-felt tumor was within easy reach of the examining forefinger. Neither the law nor common sense requires that a physician shall exercise knowledge and skill beyond the average standard in his calling, but no sophistry can justify such negligence as this. Let every mitigating circumstance be taken into consideration;—lack of time, diffidence on the physician's part, reluctance on the part of the patient to submit to an examination, and the fact remains that gross neglect has been shown. When a physician accepts a patient, he assumes trusteeship for that patient's health, and in failing to use at least three of the five senses in his behalf, he is a defaulter just as certainly as the financial trustee who dissipates by neglect or embezzlement the funds of his beneficiary. In the latter case the stake is money; but with the sick the stake is health and life. It is a scandal that a patient with symptoms pertaining to the thoracic or abdominal organs should make visit after visit to the doctor's office and be prescribed for without any sort of examination. It is a scandal when a physician sits in his office chair and prescribes for haemorrhoids on the strength of the patient's statement that he has local pain and bleeding. It is a scandal that a person is goaded into saying that in his community a patient will not get a physical examination unless he asks for it.

The laity are not fools. When after this kind of neglect, the patient repairs to some hospital clinic or consultant's office, and his true condition is revealed by a simple examination, perhaps too late to permit of cure, he cannot be blamed for disparaging the general profession and advising his friends to turn perhaps to the physio-therapeutic cultists, who at least inspire confidence by stripping their patient's physical (as well as their financial) persons for evidence of lesions, allege their discovery and apply impressive if usually misdirected measures for their relief.

Present-Day Polypharmacy

It was in 1860 that Oliver Wendell Holmes, speaking before this Society, delivered a telling blow at the prevailing practice of prescribing enormous doses of drug compounds, based on purely speculative and empirical theories of their values. His words: "I firmly believe, that if the whole materia medica, as now used, could be sunk to the bottom of the sea, it would be all the better for mankind,—and all the worse for the fishes," expressed the rising tide of dissatisfaction and distrust among physicians with respect to the polypharmacy of the day. There ensued a period of therapeutic nihilism when even remedies whose worth had apparently been proved by clinical observation were discarded because purely scientific justification for confidence in their virtues was lacking. And now we are in a fair way to swing back with the pendulum to a new phase of polypharmacy. The purposeful creation of salvarsan and its astounding effectiveness in destroying the organism of syphilis opened wide the door to new products from the limitless field of synthetic chemistry, and pharmaceutical houses flood us with samples and with evidence of plausible and credible nature concerning their value. The magical action of certain vaccines and toxins in creating specific immunity, and in rarer instances in curing disease, has led to the commercial production of bacterial remedies on a large scale, and to their urgent recommendation to the medical profession. And finally, the demonstration of the function, or at least one of the functions of the thyroid gland, and of the diseased conditions caused by its deficiency or absence, and the magical restoration to health caused by supplying the deficiency by thyroid feeding, has led to a wide-spread use of ductless gland products. The scientific investigation of the physiology, pathology and the disordered function of these organs is in its infancy, and except in the case of the thyroid, the sex glands, the pituitary and the islands of Langerhans, our knowledge of the clinical phenomena dependent on their disordered function is rudimentary. Still more are we at a loss to know how to supply their deficiency or combat their over-activity. We are in almost total ignorance of their inter-relations, which are probably very complex. And yet in spite of this absence of reliable standards and safeguards, certain investigators and clinicians are broadcasting their presumptive success in using these substances, and again some of the commercial drug manufacturers are deluging the profession with the scientific or psuedo-scientific literature of these new therapeutic agents. What has been called, "the rush to the gold fields" of endocrine therapy is in full swing, and many of our physicians are carried along in the current, anxious to be up to date in the use of the newer remedies, and trusting to leaders whose enthusiasm has perhaps out-stripped their judgment. Undoubtedly among these agents from the ductless glands lie potent aids for the relief of sickness due to endocrine mal-function, but when patient investigation by scientific methods in the laboratory and the clinic shall have finally demonstrated the methods and indications for their use, it is probable that the prevailing practice of largely empirical multi-glandular dosing will seem as unfortunate to our successors as does to us the polypharmacy of one hundred years ago.

Are there other tendencies which self-appointed critics of our profession love to dwell upon? Doubtless there are many. An elder statesman among physicians, himself a dweller in a smaller community, said in his kindly and thoughtful manner that he wished that the young doctors who settled among these people could understand the place in the hearts of the community left vacant by their predecessors for their occupancy,—the memory of their loyal service, of their pure character and disinterested friendship; the tradition of willing response by day or by night to the cry of distress, which found its adequate recompense in the lifelong unswerving allegiance of the sufferer, and such material payment as he could afford. He did not carry the theme to its conclusion, but it was quite evident that he had not found the younger generation always capable of or perhaps disposed to filling those treasured places. But these are more personal matters, pertaining more perhaps to the spirit of the age than to the practice of medicine.

The Golden Age of Medicine

We are living in the Golden Age of Medicine. Doubtless our forebears through the centuries have held the same belief about their eras, but we feel justly that we can scarcely be deceived about our own. Future years will far transcend the present in knowledge, in control over physical forces, in ability to prevent and cure disease and injury, but these years will be the direct continuation of the present age of scientific medicine. It has passed successively through the age of medical theism, the Hippocratic age of observation and dependence on Nature, of Galenic authority, of speculative concepts of the nature of disease on which were based arbitrary systems of therapeutics, until the present era which had its vague beginnings in the Renaissance, and has progressed by the observation and recording of facts, by inductive reasoning from those facts, by the broadening of the scope of observed phenomena by the invention of countless scientific instruments and by rationally planned experimentation. We recognize no authority but truth. If a long-cherished belief or viewpoint about any phase of disease, apparently firmly based on scientific evidence, is shattered by further research or experience, there is no teacher so influential, no medical despot with such prestige, as to prevent the lopping-off of the misshapen branch from the tree of knowledge, and the grafting on of the new bud. No arbitrary system or dogma longer holds sway, and as the advance of knowledge is limitless, so also will be the progress of medical science. This is the prospect before us physicians, and these the conditions under which we work as custodians of the health of the people.

Nineteen centuries ago, in the Golden Age of the Roman Empire when the simple virtues upon which was built the majesty of Rome were beginning to weaken under the influence of luxury and wealth and indolence, the satirist Juvenal uttered the cynical question: “Quis custodiet ipsos custodes?"—and offered no answer to enlighten his fellow citizens. Who shall indeed guard the custodian of a great cause? Is there a higher authority which can provide against his possible malfeasance? Our calling, which is justly deemed noble, shows no weakening of the morale of its militant hosts in its never ending warfare against disease, but here and there, among the rank and file, a foothold is gained by some of the meaner attributes of human nature;—selfishness, greed, indolence, self-indulgence, intellectual dishonesty, which give comfort and opportunity to those who are ever ready to disparage us. But were there a modern Juvenal to taunt us with his question, an answer would be found in the mandate of this Society. It has always represented through the words and acts of its leaders, the highest example of the blameless physician. The story of its influence on our Commonwealth can never be fully known, but it is told in that splendid narrative from the pen of a living Fellow, who from the leisure imposed by physical disability gained the opportunity;—as he had always had the will, to record its history and traditions in permanent form. It is the Massachusetts Medical Society which shall act as the guardian of its Fellows in their custodianship of the public health!

Fortitude to face the influences which undermine morale, encouragement to be steadfast to principle is gained by association with like-minded men. Let us then gather at the annual festivals of this Society of ours, and in the handclasp of fellowship gain resolution to persevere; let us break the bread and eat the salt of friendship and re-dedicate ourselves to our splendid calling.

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Cheever, David. "The Physician as Custodian of the Health of the People: But Who Shall Guard the Custodian Himself?". The Boston Medical and Surgical Journal 192, no. 24 (1925): 1143-51.

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