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THE MEDICAL PRACTICE ACT VERSUS PUBLIC
THOMAS J. CROWE, M.D.
Much has been said and more written on the failure to enforce the penalty provisions of the medical practice acts of the several states, but neither speaker nor writer has mentioned the basic cause of such failure. In recent discussions of the failure of state authorities to regulate the art of healing, as modern, scientific physicians would have it regulated, there has been no mention of the psychology of the history of medicine as the primal cause of the indifference with which medical practice acts are regarded by the legislator, the prosecutor and the public.
It must be apparent to all who have given the matter serious thought that the history of medicine, in all phases of the development of what is now known as scientific medicine, parallels the history of religion. Religion and medicine were both born in supernatural environments and both were handed down clothed with mystery and superstition, and accompanied by a traditional psychology from which it is difficult to disassociate them in the mind of the public.
In the beginning medical as well as religious practices were in the hands of priests, who taught that all diseases, deformities and injuries were due to the presence in the body of the afflicted individual of evil spirits which must be cast out, and that such sufferings had been imposed as a punishment by an offended god or deity. Hence the offerings, prayers, incantations and the exorcisms of the early days. The Bible contributes much to this traditional psychology, as in the mystery of the parable of the loaves and fishes and in the story of the ten Samaritans who were cured of leprosy.
If one is foolish enough to believe that a traditional psychology may be dispelled in a day, a month or a year, or if he is unwilling to admit that mystery and superstition still cling to the popular conception of disease, not only in the minds of the ignorant, but also in the minds of the cultured, inclusive of preachers, teachers and jurists, all he has to do in order to be convinced of his error is to notice the size and composition of the crowds that appear for treatment when a well-advertised medical mountebank or a preacher with a reputation for having made “wonderful cures” visits a city or town; or to observe the ease with which practitioners of a highly-touted, new system of healing develop a lucrative practice.
That such a psychology does exist, and that it may be found in the church, the school, the legislature and the court-house, is easily proved. That it requires only the incidence of what appears to be a miraculous cure, (in reality only the natural result of normal physiological processes) at the hands of an ignorant cultist or a religious fanatic, to start a flood-tide of favorable public sentiment, on the crest of which the practitioner may be carried to fame and fortune, and against which neither legislator nor prosecutor can long hold out, is also obvious to those who have made a serious study of enforcement.
We may and do know how it happened that John Smith went to bed apparently well—“feeling fine," as he said-Monday night, and awoke Tuesday morning with the chill and other symptoms of pneumonia. But does the sick man know, or will he believe us when we tell him, that millions of fivisible animals (germs), not
This is the fifth paper on the symposium on “Essential Principles of a Medical Practice Act." read before the Annual Congress on Medical Education, Medical Licensure, Public Health and Hospitals, Chicago, March 11, 1925.
a single one of which he has seen, heard, smelled, tasted or felt, have invaded his body and are attempting to take his life? How much easier it was later on for Smith), your former patient, to believe that the pain in his side (from pneumonia or pleurisy) was due to a slipped vertebrae or a pinched nerve? It was simple enough to him when his chiropractor presented a picture of an assembled spine with a rubber tube, taken from a fountain syringe. passed through one of the foramen where it appeared to be pinched. Smith could associate a pain with a pinch, and he had a concrete example of it before him to fix the association in his minul. There was nothing mysterious about it. It seemed reasonable.
I recall a public hearing in 1923 by the Public Health Committee of the Texas legislature, which then had before it two medical bills, one presented by the legalized medical profession, and another submitted by the chiropractors who had asked for legalization and an independent board of examiners. The medical bill, having been introduced first, was given the first hearing. The proponents of this bill explained in detail the importance of medical education and scientific training in the practice of medicine, and told why they believed that ignorant, incompetent practitioners should be stopped. When the medical men had presented the merits of their bill, their opponents were given the floor.
USE OF FAULTY DEMONSTRATIONS Did the chiropractors discuss education or science? Oh, no! They presented concrete examples of what they regarded as positive evidence of their wonderful ability as healers. They were out, in force, to develop a psychology unfavorable to the proponents of the medical bill. How did they do it? (I described this hearing two years ago.) Instead of talking science, of which they knew nothing, the chiropractors arranged a table near that of the committee and placed on it. in a standing position, a girl of fifteen who, before a large and interested audience, exposed a leg on which, midway between the knee and the hip, there was a deformity that resembled the hump on a camel's back. In explanation of the deformity, the chiropractors said that when this patient came into their hands, after having been treated by one doctor after another and after having been operated on by one surgeon after another for two years, a large section of the bone, femur, was exposed, and that great quantities of blood and corruption constantly came away from it. "Look at her now!" said they. “She has a useful if not a beautiful limb." "Thank God for the Chiropractor!" shouted the girl's mother, “Why should not these wonderful men be permitted to do that which the medical doctors could not do—rescue my child from premature death?" A legislator nudged a companion and whispered: "Wonderful!" And the large audience gave vent to its enthusiastic approval of what seemed to be a miraculous cure.
The next case presented was that of a girl of twenty, who said she had suffered a severe blood-poisoning that left her deaf, dumb and blind; that for more than a year she had been in the hands of the most skilled physicians without result; and that they had failed to restore hearing, speech or sight. “Look at me now!" she shouted. “I see you, I hear you, I am talking to you. Thank God for the Chiropractor! Why should not these wonderful healers be permitted to restore afflicted humans to health and usefulness-to lift them out of the pitiable, helpless, hopeless condition in which they were left by the medical doctors?" Again the legislator nudged his companion and whispered: “Marvelous !” Again the hall rang with an outburst of applause from the audience.
During the applause following the chiropractic demonstration, a woman in the rear of the hall mounted a chair and clamored for recognition. When the noise had subsided so that she could be heard, she stated that from her seventh to her twenty-first year she was an invalid, constantly in the hands of the best medical doctors available, but without improvement. “One Christian science treatment, and I'm a well woman,” she shouted. “Thank God for the Science Healers! Why should these God-given practitioners be driven out of the art of healing? Why should they not be permitted to restore the hopeless derelicts for whom the medical doctors could do nothing?" Again the legislator nudged his friend and passed a significant glance. Again the capitol rocked with thunderous applause for the scientist, who had capped the climax and completed the rout of the medical men.
When the hearing was concluded, the crowd present looked on and treated the medical men present about as it would have treated them had they been caught in the act of robbing a baby's bank.
Had such a demonstration been made in an executive session of the legislature while the chiropractic bill or a Christian science exemption was under consideration, either or both would have been enacted by an overwhelming majority. Why? ? ? Because the medical men failed to deliver an effective, enlightening counter offensive—made no attempt to explain cures that had resulted from natural, physiologic processes; because they failed to dispel a false but awe-inspiring psychology that had been established in the minds of legislators and of the hundreds of others present with a simple, truthful statement of facts.
SHOULD HAVE Regarding the girl first presented, they might have explained that she had suffered tuberculosis of the femur, and that while the germs were destroying the old bone, nature made an effort to save her leg and life, by building a shell of new bone around the old one; that to hasten the reparative process the surgeon from time to time cut into this shell and removed loose pieces of dead bone, the disintegration and drainage away of which would have required months and probably would have caused the death of the patient, from exhaustion and toxemia, before the old bone could be completely discharged; that when the last portion of dead bone had been removed this child would have recovered had she been a thousand miles from the nearest chiropractor or doctor ; that had she remained in the hands of the surgeon she would now have a straight, useful leg, because he would have put a brace or a cast on it to take care of her weight and to prevent sagging or buckling of the new, soft bone; and that then she would have been a hundred times better off than she was left by the chiropractor, whose ignorance of disease and of physiologic repair had resulted in his failure to adjust a brace or put on a cast to support the weight of her body while the new bone was filling in and hardening. Instead of taking this precaution, the chiropractor allowed her to bear her weight on the soft, new bone too early which caused it to bend and thus cripple her for life. But, to this day, neither the legislators nor the hundreds of persons in the audience knew this. They could not guess it.
Of the blood-poisoning case the medical man might at least have explained that this young lady suffered an overwhelming and nearly fatal blood-poisoning that interfered with the function of tissues and organs, and this interference, as well as the recovery after it was overcome, could have been easily explained.
EXPLANATIONS But our representatives in the hearing did not make these explanations. Instead, they smiled complacently at the ignorance of the chiropractor, sneered at the absurdity of his argument, and took it for granted that the legislators present and the intelligent persons in the audience had sense enough to realize his incompetence. The medical men could not understand why neither the legislator nor audience could see or interpret the cases presented as they had seen and interpreted them. Physicians are strong for teaching psychology, but they seem to have overlooked its usefulness. They do not practice it.
But, you ask, what has psychology to do with enforcement? It has everything to do with it; for while antagonistic psychology or adverse public sentiment exists in a community or a state, its medical practice laws cannot be effectually enforced. The sooner medical men realize this fact, the better it will be for all concerned.
PICTORIAL EDUCATION That such a psychology exists in the minds of a large number of persons in every community is undeniable. But how shall we meet and counteract it? The answer is by education, not in high-sounding words from a vocabulary that would be wasted if used on the man of the street, but by presenting, in a dignified, ethical way, object lessons, or concrete examples of the causes and the cure of disease, so that the ignorant as well as the intelligent auditor may get a correct conception of them. But this cannot be successfully done without the presentation of something concrete on which to fix a conception, any more than it would be possible to master bacteriology without the use of the microscope or enlarged photomicrographs of germs. What conception would you and I now have of a red or white blood cell, if we had never seen them in the field of a microscope ?
One might talk about germs for a thousand years, and his auditors would have no fixed conception of them until they had seen them in the field of a microscope, or in pictures in a book or on the screen. If the germs of communicable diseases were presented on the screen, just as recently discovered and captured wild animals are presented in a moving picture theater, then the observer-adult or child, literate or illiterate—would get a conception of them which he or she could associate with the presence of disease and make use of in än effort to escape exposure to them. The presentation of something concrete was what the chiropractor had in mind when he presented the picture of the spine with a pinched rubber tube sticking out of a foramen, and he made it serve his purpose.
In the language of the military, let us lay dowrf an effective barrage of pictorial education; that is, secure an add ion to the grammar-school curriculum of a properly illustrated, primary work on personal hygiene and public health, inclusive of rudimentary bacteriology; go into the picture shows with enlarged photomicrographs of the germs of transmissible diseases, in order to fix a correct conception of them, in a "Safety First" campaign on public health; and present speakers on health subjects in the church, school room, theater, social clubs and business men's luncheons, and thus drop a curtain of educational shrapnel in front of the advancing lines of our ancient enemies, ignorance and superstition, and stop them in their tracks. Don't make the mistake of shooting over their heads, thus permitting them to deliver a surprise attack and capture us in our dugouts while we wait for the “zero hour.”
Modern, scientific, medical men seem to have been content to wrap themselves in a cloak of intellectuality, to sneer at or to ridicule the ignorant cultist, and to allow the public to go on wondering whether the story of the invisible bugs is true, and if so, why the earth had not been depopulated long ago. Since the average man has no conception of cellular resistance, it is only natural that such a thought should occur to him. Then why should we not help him to get a correct and lasting conception of disease and of medical science, so that he may stop groping in darkness and grasping at straws ?
EDUCATIONAL CAMPAIGN IN Two years ago, when the injunction feature was added to the Texas medical practice act, the medical profession of Texas was in doubt as to what action it should take on enforcement; whether to commence the prosecution of violations at once, or to wait and first try to develop a favorable psvchology (public sentiment) by putting on a campaign of education. It was finally decided that it would be better "to make haste slowly” than to make the mistake of rushing into conflict with an adverse public sentiment, and probably get the wosst of the encounter.
In order to put over the educational campaign, the Texas Medical Association increased its annual membership fee from five to fifteen dollars, and thus raised approximately $50,000. Speakers were sent to different parts of the state to address public meetings, to appear before social organizations and before business men's clubs, as the Rotary, Kiwanis and others, and to speak on public health in schools, churches and everywhere they could talk to advantage. In connection
with the educational campaign, the association made it a point to investigate the attitude on medical education and on public health of every candidate for public office, from that of governor to county attorney, and to secure, if possible, the defeat on election day of every office seeker who had indicated opposition to either.
That these campaigns were very effectual we have had ample evidence, since many of those who had opposed public health legislation in the thirty-eighth legislature were defeated at the polls; and it was further emphasized when the thirtyninth, or present legislature, quickly rendered "hors du combat" the chiropractor's biennial bill. The average legislator is a reasonable, sensible man, disposed to do that which is in the interest of the general weliare, if he has had correct information on the proposition.
In our haste to find a solution for the enforcement problem, we seem to have overlooked the fact that it is just as impossible to legislate or to prosecute false conceptions (erroneous psychology) out of the public mind, as it is to legislate or to prosecute conscience, correct principles or morality into it. We seem also to have overlooked the fact that, thus far, all attempts at discriminative legislation, regardless of their purpose, have signally failed. SOLUTION
ENFORCEMENT PROBLEM I might go farther and say that the salvation of ethical, scientific medicine depends on the diligence with which medical men, interested in the welfare of the registered profession and the future of the public health, pursue two lines of important endeavor: one, the rapid and effectual education of the public by the use of the screen and the grammar-school text book on public health, to fix proper conceptions; the other, the universal adoption of an adequate, single standard of medical education in the essential fundamentals, particularly in those subjects that are of vital concern to the public health, as the causes, propagation and transmission of communicable diseases, and their recognition, or diagnosis, which shall be exacted of every person who seeks the license to engage in the art of healing.
That the single standard, such as was adopted by the state of Texas, is successful, we have had ample evidence. Our greatest difficulty in the maintenance of it is to satisfactorily explain to our legislature and to our courts why a chiropractor who is good enough for legalization in Ohio and twenty-five other states is not fit for registration in Texas. MULTIPLE BOARD
LIMITED LICENSES The multiple board system and the limited license, which my friend, Bonner, of North Carolina, regarded two years ago as "infinitely superior" to the single standard and the mixed board, is scientific medicine's most dangerous menace. Multiple boards mean multiple standards, and multiple standards are equivalent to no standards at all. A state may issue what it calls a limited license, but it is certainly powerless to limit the practitioner's use of it. He cannot be held within the limits prescribed by it; hence, he attempts to resort to other means, and in effect becomes a medical “bootlegger.” Furthermore, all of the crookedness in medical registration of which I have any knowledge has developed in states that maintain multiple examining boards.
Satisfactory enforcement depends on the general adoption of an adequate, nondiscriminative, single standard of medical education, and this means a standard from which methods of treatment have been eliminated, because the state has neither the moral nor the legal right to control treatment nor to prohibit a commendable use of education or judgment; nor should it attempt to do so, any more than it would attempt to say what or when one shall eat, or when or where one may pray. Such a standard can be effectually enforced, and, besides solving the problem of enforcement, it will eventually and automatically eliminate the cuits. Tecause, when a medical student has mastered anatomy, physiology, pathology, histology, bacteriology, diagnosis and hygiene, he will have little use for the fallacies with which he may have commenced the medical course.