Medical Nemesis
1
The Epidemics
of Modern Medicine
During the past three generations the diseases afflicting Western
societies have undergone dramatic changes.1 Polio, diphtheria, and
tuberculosis are vanishing; one shot of an antibiotic often cures
pneumonia or syphilis; and so many mass killers have come under control
that two-thirds of all deaths are now associated with the diseases of
old age. Those who die young are more often than not victims of
accidents, violence, or suicide.2
These changes in
health status are generally equated with a decrease in suffering and
attributed to more or to better medical care. Although almost everyone
believes that at least one of his friends would not be alive and well
except for the skill of a doctor, there is in fact no evidence of any
direct relationship between this mutation of sickness and the so-called
progress of medicine.3 The changes are
dependent
variables of political and technological transformations, which in turn
are reflected in what doctors do and say; they are not significantly
related to the activities that require the preparation, status, and
costly equipment in which the health professions take pride.4 In
addition, an expanding proportion of the new burden of disease of the
last fifteen years is itself the result of medical intervention in
favor of people who are or might become sick. It is doctor-made, or
iatrogenic?
After a century of pursuit of medical
Utopia,6 and contrary to current conventional wisdom,7 medical services
have not been important in producing the changes in life expectancy
that have occurred. A vast amount of contemporary clinical care is
incidental to the curing of disease, but the damage done by medicine to
the health of individuals and populations is very significant. These
facts are obvious, well documented, and well repressed.
Doctors' Effectiveness—An Illusion
The study of the evolution of disease patterns provides evidence that
during the last century doctors have affected epidemics no more
profoundly than did priests during earlier times. Epidemics came and
went, imprecated by both but touched by neither. They are not modified
any more decisively by the rituals performed in medical clinics than by
those customary at religious shrines.8 Discussion of the future of
health care might usefully begin with the recognition of this fact.
The infections that prevailed at the outset of the industrial age
illustrate how medicine came by its reputation.9 Tuberculosis, for
instance, reached a peak over two generations. In New York in 1812, the
death rate was estimated to be higher than 700 per 10,000; by 1882,
when Koch first isolated and cultured the bacillus, it had already
declined to 370 per 10,000. The rate was down to 180 when the first
sanatorium was opened in 1910, even though "consumption" still held
second place in the mortality tables,10 After World War II, but before
antibiotics became routine, it had slipped into eleventh place with a
rate of 48. Cholera,11 dysentery,12 and typhoid similarly peaked and
dwindled outside the physician's control. By the time their etiology
was understood and their therapy had become specific, these diseases
had lost much of their virulence and hence their social importance. The
combined death rate from scarlet fever, diphtheria, whooping cough, and
measles among children up to fifteen shows that nearly 90 percent of
the total decline in mortality between 1860 and 1965 had occurred
before the introduction of antibiotics and widespread immunization.13
In part this recession may be attributed to improved housing and to a
decrease in the virulence of micro-organisms, but by far the most
important factor was a higher host-resistance due to better nutrition.
In poor countries today, diarrhea and upper-respiratory-tract
infections occur more frequently, last longer, and lead to higher
mortality where nutrition is poor, no matter how much or how little
medical care is available.14 In England, by the middle of the
nineteenth century, infectious epidemics had been replaced by major
malnutrition syndromes, such as rickets and pellagra. These in turn
peaked and vanished, to be replaced by the diseases of early childhood
and, somewhat later, by an increase in duodenal ulcers in young men.
When these declined, the modern epidemics took over: coronary heart
disease, emphysema, bronchitis, obesity, hypertension, cancer
(especially of the lungs), arthritis, diabetes, and so-called mental
disorders. Despite intensive research, we have no complete explanation
for the genesis of these changes.15 But two things are certain: the
professional practice of physicians cannot be credited with the
elimination of old forms of mortality or morbidity, nor should it be
blamed for the increased expectancy of life spent in suffering from the
new diseases. For more than a century, analysis of disease trends has
shown that the environment is the primary determinant of the state of
general health of any population.16 Medical geography,17 the history of
diseases,18 medical anthropology,19 and the social history of attitudes
towards illness20 have shown that food,21 water,22 and air,23 in
correlation with the level of sociopolitical equality24 and the
cultural mechanisms that make it possible to keep the population
stable,25 play the decisive role in determining how healthy grown-ups
feel and at what age adults tend to die. As the older causes of disease
recede, a new kind of malnutrition is becoming the most rapidly
expanding modern epidemic.26 One-third of humanity survives on a level
of undernourishment which would formerly have been lethal, while more
and more rich people absorb ever greater amounts of poisons and
mutagens in their food.27
Some modern techniques,
often developed with the help of doctors, and optimally effective when
they become part of the culture and environment or when they are
applied independently of professional delivery, have also effected
changes in general health, but to a lesser degree. Among these can be
included contraception, smallpox vaccination of infants, and such
nonmedical health measures as the treatment of water and sewage, the
use of soap and scissors by midwives, and some antibacterial and
insecticidal procedures. The importance of many of these practices was
first recognized and stated by doctors—often courageous dissidents who
suffered for their recommendations28—but this does not consign soap,
pincers, vaccination needles, delousing preparations, or condoms to the
category of "medical equipment." The most recent shifts in mortality
from younger to older groups can be explained by the incorporation of
these procedures and devices into the layman's culture.
In contrast to environmental improvements and modern nonprofessional
health measures, the specifically medical treatment of people is never
significantly related to a decline in the compound disease burden or to
a rise in life expectancy.29 Neither the proportion of doctors in a
population nor the clinical tools at their disposal nor the number of
hospital beds is a causal factor in the striking changes in over-all
patterns of disease. The new techniques for recognizing and treating
such conditions as pernicious anemia and hypertension, or for
correcting congenital malformations by surgical intervention, redefine
but do not reduce morbidity. The fact that the doctor population is
higher where certain diseases have become rare has little to do with
the doctors' ability to control or eliminate them.30 It simply means
that doctors deploy themselves as they like, more so than other
professionals, and that they tend to gather where the climate is
healthy, where the water is clean, and where people are employed and
can pay for their services.31
Useless Medical Treatment
Awe-inspiring medical technology has combined with egalitarian rhetoric
to create the impression that contemporary medicine is highly
effective. Undoubtedly, during the last generation, a limited number of
specific procedures have become extremely useful. But where they are
not monopolized by professionals as tools of their trade, those which
are applicable to widespread diseases are usually very inexpensive and
require a minimum of personal skills, materials, and custodial services
from hospitals. In contrast, most of today's skyrocketing medical
expenditures are destined for the kind of diagnosis and treatment whose
effectiveness at best is doubtful.32 To make this point I will
distinguish between infectious and noninfectious diseases.
In the case of infectious diseases, chemotherapy has played a
significant role in the control of pneumonia, gonorrhea, and syphilis.
Death from pneumonia, once the "old man's friend," declined yearly by 5
to 8 percent after sulphonamides and antibiotics came on the market.
Syphilis, yaws, and many cases of malaria and typhoid can be cured
quickly and easily. The rising rate of venereal
disease is due to new mores, not to ineffectual medicine. The
reappearance of malaria is due to the development of
pesticide-resistant mosquitoes and not to any lack of new antimalarial
drugs.33 Immunization has almost wiped out paralytic poliomyelitis, a
disease of developed countries, and vaccines have certainly contributed
to the decline of whooping cough and measles,34 thus seeming to confirm
the popular belief in "medical progress." 35 But for most other
infections, medicine can show no comparable results. Drug treatment has
helped to reduce mortality from tuberculosis, tetanus, diphtheria, and
scarlet fever, but in the total decline of mortality or morbidity from
these diseases, chemotherapy played a minor and possibly insignificant
role.36 Malaria, leishmaniasis, and sleeping sickness indeed receded
for a time under the onslaught of chemical attack, but are now on the
rise again.37
The effectiveness of medical
intervention in combatting noninfectious diseases is even more
questionable. In some situations and for some conditions, effective
progress has indeed been demonstrated: the partial prevention of caries
through fluoridation of water is possible, though at a cost not fully
understood.38 Replacement therapy lessens the direct impact of
diabetes, though only in the short run.39 Through intravenous feeding,
blood transfusions, and surgical techniques, more of those who get to
the hospital survive trauma, but survival rates for the most common
types of cancer—those which make up 90 percent of the cases—have
remained virtually unchanged over the last twenty-five years. This fact
has consistently been clouded by announcements from the American Cancer
Society reminiscent of General Westmoreland's proclamations from
Vietnam. On the other hand, the diagnostic value of the Papanicolaou
vaginal smear test has been proved: if the tests are given four times a
year, early intervention for cervical cancer demonstrably increases the
five-year survival rate. Some skin-cancer treatment is highly
effective. But there is little evidence of effective treatment of most
other cancers.40 The five-year survival rate in breast-cancer cases is
50 percent, regardless of the frequency of medical check-ups and
regardless of the treatment used.41 Nor is there evidence that the rate
differs from that among untreated women. Although practicing doctors
and the publicists of the medical establishment stress the importance
of early detection and treatment of this and several other types of
cancer, epidemiologists have begun to doubt that early intervention can
alter the rate of survival.42 Surgery and chemotherapy for rare
congenital and rheumatic heart disease have increased the chances for
an active life for some of those who suffer from degenerative
conditions.43 The medical treatment of common cardiovascular disease44
and the intensive treatment of heart disease,45 however, are effective
only when rather exceptional circumstances combine that are outside the
physician's control. The drug treatment of high blood pressure is
effective and warrants the risk of side-effects in the few in whom it
is a malignant condition; it represents a considerable risk of serious
harm, far outweighing any proven benefit, for the 10 to 20 million
Americans on whom rash artery-plumbers are trying to foist it.46
Doctor-Inflicted Injuries
Unfortunately, futile but otherwise harmless medical care is the least
important of the damages a proliferating medical enterprise inflicts on
contemporary society. The pain, dysfunction, disability, and anguish
resulting from technical medical intervention now rival the morbidity
due to traffic and industrial accidents and even war-related
activities, and make the impact of medicine one of the most rapidly
spreading epidemics of our time. Among murderous institutional torts,
only modern malnutrition injures more people than iatrogenic disease in
its various manifestations.47 In the most narrow sense, iatrogenic
disease includes only illnesses that would not have come about if sound
and professionally recommended treatment had not been applied.48 Within
this definition, a patient could sue his therapist if the latter, in
the course of his management, failed to apply a recommended treatment
that, in the physician's opinion, would have risked making him sick. In
a more general and more widely accepted sense, clinical iatrogenic
disease comprises all clinical conditions for which remedies,
physicians, or hospitals are the pathogens, or "sickening" agents. I
will call this plethora of therapeutic side-effects clinical
iatrogenesis. They are as old as medicine itself,49 and have always
been a subject of medical studies.50
Medicines have
always been potentially poisonous, but their unwanted side-effects have
increased with their power31 and widespread use.52 Every twenty-four to
thirty-six hours, from 50 to 80 percent of adults in the United States
and the United Kingdom swallow a medically prescribed chemical. Some
take the wrong drug; others get an old or a contaminated batch, and
others a counterfeit;53 others take several drugs in dangerous
combinations;54 and still others receive injections with improperly
sterilized syringes.55 Some drugs are addictive, others mutilating, and
others mutagenic, although perhaps only in combination with food
coloring or insecticides. In some patients, antibiotics alter the
normal bacterial flora and induce a superinfection, permitting more
resistant organisms to proliferate and invade the host. Other drugs
contribute to the breeding of drug-resistant strains of bacteria.56
Subtle kinds of poisoning thus have spread even faster than the
bewildering variety and ubiquity of nostrums.57 Unnecessary surgery is
a standard procedure.58 Disabling nondiseases result from the medical
treatment of nonexistent diseases and are on the increase:59 the number
of children disabled in Massachusetts through the treatment of cardiac
non-disease exceeds the number of children under effective treatment
for real cardiac disease.60
Doctor-inflicted pain
and infirmity have always been a part of medical practice.61
Professional callousness, negligence, and sheer incompetence are
age-old forms of malpractice.62 With the transformation of the doctor
from an artisan exercising a skill on personally known individuals into
a technician applying scientific rules to classes of patients,
malpractice acquired an anonymous, almost respectable status.63 What
had formerly been considered an abuse of confidence and a moral fault
can now be rationalized into the occasional breakdown of equipment and
operators. In a complex technological hospital, negligence becomes
"random human error" or "system breakdown," callousness becomes
"scientific detachment," and incompetence becomes "a lack of
specialized equipment." The depersonalization of diagnosis and therapy
has changed malpractice from an ethical into a technical problem.64
In 1971, between 12,000 and 15,000 malpractice suits were lodged in
United States courts. Less than half of all malpractice claims were
settled in less than eighteen months, and more than 10 percent of such
claims remain unsettled for over six years. Between 16 and 20 percent
of every dollar paid in malpractice insurance went to compensate the
victim; the rest was paid to lawyers and medical experts.65 In such
cases, doctors are vulnerable only to the charge of having acted
against the medical code, of the incompetent performance of prescribed
treatment, or of dereliction out of greed or laziness. The problem,
however, is that most of the damage inflicted by the modern doctor does
not fall into any of these categories.66 It occurs in the ordinary
practice of well-trained men and women who have learned to bow to
prevailing professional judgment and procedure, even though they know
(or could and should know) what damage they do.
The
United States Department of Health, Education, and Welfare calculates
that 7 percent of all patients suffer compensable injuries while
hospitalized, though few of them do anything about it. Moreover, the
frequency of reported accidents in hospitals is higher than in all
industries but mines and high-rise construction. Accidents are the
major cause of death in American children. In proportion to the time
spent there, these accidents seem to occur more often in hospitals than
in any other kind of place. One in fifty children admitted to a
hospital suffers an accident which requires specific treatment.67
University hospitals are relatively more pathogenic, or, in blunt
language, more sickening. It has also been established that one out of
every five patients admitted to a typical research hospital acquires an
iatrogenic disease, sometimes trivial, usually requiring special
treatment, and in one case in thirty leading to death. Half of these
episodes result from complications of drug therapy; amazingly, one in
ten comes from diagnostic procedures.68 Despite good intentions and
claims to public service, a military officer with a similar record of
performance would be relieved of his command, and a restaurant or
amusement center would be closed by the police. No wonder that the
health industry tries to shift the blame for the damage caused onto the
victim, and that the dope-sheet of a multinational pharmaceutical
concern tells its readers that "iatrogenic disease is almost always of
neurotic origin." 69
Defenseless Patients
The undesirable side-effects of approved, mistaken, callous, or
contraindicated technical contacts with the medical system represent
just the first level of pathogenic medicine. Such clinical iatrogenesis
includes not only the damage that doctors inflict with the intent of
curing or of exploiting the patient, but also those other torts that
result from the doctor's attempt to protect himself against the
possibility of a suit for malpractice. Such attempts to avoid
litigation and prosecution may now do more damage than any other
iatrogenic stimulus.
On a second level,70 medical
practice sponsors sickness by reinforcing a morbid society that
encourages people to become consumers of curative, preventive,
industrial, and environmental medicine. On the one hand defectives
survive in increasing numbers and are fit only for life under
institutional care, while on the other hand, medically certified
symptoms exempt people from industrial work and thereby remove them
from the scene of political struggle to reshape the society that has
made them sick. Second-level iatrogenesis finds its expression in
various symptoms of social overmedicalization that amount to what I
shall call the expropriation of health. This second-level impact of
medicine I designate as social iatrogenesis, and I shall discuss it in
Part II.
On a third level, the so-called health
professions have an even deeper, culturally health-denying effect
insofar as they destroy the potential of people to deal with their
human weakness, vulnerability, and uniqueness in a personal and
autonomous way. The patient in the grip of contemporary medicine is but
one instance of mankind in the grip of its pernicious techniques.71
This cultural iatrogenesis, which I shall discuss in Part III, is the
ultimate backlash of hygienic progress and consists in the paralysis of
healthy responses to suffering, impairment, and death. It occurs when
people accept health management designed on the engineering model, when
they conspire in an attempt to produce, as if it were a commodity,
something called "better health." This inevitably results in the
managed maintenance of life on high levels of sublethal illness. This
ultimate evil of medical "progress" must be clearly distinguished from
both clinical and social iatrogenesis.
I hope to
show that on each of its three levels iatrogenesis has become medically
irreversible: a feature built right into the medical endeavor. The
unwanted physiological, social, and psychological by-products of
diagnostic and therapeutic progress have become resistant to medical
remedies. New devices, approaches, and organizational arrangements,
which are conceived as remedies for clinical and social iatrogenesis,
themselves tend to become pathogens contributing to the new epidemic.
Technical and managerial measures taken on any level to avoid damaging
the patient by his treatment tend to engender a self-reinforcing
iatrogenic loop analogous to the escalating destruction generated by
the polluting procedures used as antipollution devices.72
I will designate this self-reinforcing loop of negative institutional
feedback by its classical Greek equivalent and call it medical nemesis.
The Greeks saw gods in the forces of nature. For them, nemesis
represented divine vengeance visited upon mortals who infringe on those
prerogatives the gods enviously guard for themselves. Nemesis was the
inevitable punishment for attempts to be a hero rather than a human
being. Like most abstract Greek nouns, Nemesis took the shape of a
divinity. She represented nature's response to hubris: to the
individual's presumption in seeking to acquire the attributes of a god.
Our contemporary hygienic hubris has led to the new syndrome of medical
nemesis.73
By using the Greek term I want to
emphasize that the corresponding phenomenon does not fit within the
explanatory paradigm now offered by bureaucrats, therapists, and
ideologues for the snowballing diseconomies and disutilities that,
lacking all intuition, they have engineered and that they tend to call
the "counterintuitive behavior of large systems." By invoking myths and
ancestral gods I should make it clear that my framework for analysis of
the current breakdown of medicine is foreign to the industrially
determined logic and ethos. I believe that the reversal of nemesis can
come only from within man and not from yet another managed
(heteronomous) source depending once again on presumptious expertise
and subsequent mystification.
Medical nemesis is
resistant to medical remedies. It can be reversed only through a
recovery of the will to self-care among the laity, and through the
legal, political, and institutional recognition of the right to care,
which imposes limits upon the professional monopoly of physicians. My
final chapter proposes guidelines for stemming medical nemesis and
provides criteria by which the medical enterprise can be kept within
healthy bounds. I do not suggest any specific forms of health care or
sick-care, and I do not advocate any new medical philosophy any more
than I recommend remedies for medical technique, doctrine, or
organization. However, I do propose an alternative approach to the use
of medical organization and technology together with the allied
bureaucracies and illusions.
-------------------------------------------
1 Erwin H. Ackerknecht, History and Geography of the Most Important Diseases (New York: Hafner, 1965).
2 Odin W. Anderson and Monroe Lerner, Measuring Health Levels in the
United States, 1900-1958, Health Information Foundation Research Series
no. 11 (New York: Foundation, 1960). Marc Lalonde, A New Perspective on
the Health of Canadians: A Working Document (Ottawa: Government of
Canada, April 1974). This courageous French-English report by the
Canadian Federal Secretary for Health contains a multicolored
centerfold documenting the change in mortality for Canada in a series
of graphs.
3 René Dubos, The Mirage of Health:
Utopian Progress and Biological Change (New York: Anchor Books, 1959),
was the first to effectively expose the delusion of producing "better
health" as a dangerous and infectious medically sponsored disease.
Thomas McKeown and Gordon McLachlan, eds., Medical History and Medical
Care: A Symposium of Perspectives (New York: Oxford Univ. Press, 1971),
introduce the sociology of medical pseudo-progress. John Powles, "On
the Limitations of Modern Medicine," in Science, Medicine and Man
(London: Pergamon, 1973), 1:1-30, gives a critical selection of recent
English-language literature on this subject. For the U.S. situation
consult Rick Carlson, The End of Medicine (New York: Wiley
Interscience, 1975). His essay is "an empirically based brief,
theoretical in nature." For his indictment of American medicine he has
chosen those dimensions for which he had complete evidence of a nature
he could handle. Jean-Claude Polack, La Médecine du capital (Paris:
Maspero, 1970). A critique of the political trends that seek to endow
medical technology with an effective impact on health levels by a
"democratization of medical consumer products." The author discovers
that these products themselves are shaped by a repressive and
alienating bourgeois class structure. To use medicine for political
liberation it will be necessary to "find in sickness, even when it is
distorted by medical intervention, a protest against the existing
social order."
4 Daniel Greenberg, "The 'War on
Cancer': Official Fiction and Harsh Facts," Science and Government
Report, vol. 4 (December 1, 1974). This well-researched report to the
layman substantiates the view that American Cancer Society
proclamations that cancer is curable and progress has been made are
"reminiscent of Vietnam optimism prior to the deluge."
5 Borland's Illustrated Medical Dictionary, 25th ed. (Philadelphia:
Saunders, 1974): "Iatrogenic (iatro—Gr. physician, gennan—Gr. to
produce). Resulting from the activity of physicians. Originally applied
to disorders induced in the patient by autosuggestion based on the
physician's examination, manner, or discussion, the term is now applied
to any adverse condition in a patient occurring as the result of
treatment by a physician or surgeon."
6 Heinrich
Schipperges, Utopien der Medizin: Geschichte und Kritik der ärtztlichen
Ideologic des 19. Jh. (Salzburg: Miiller, 1966). A useful guide to the
historical literature is Richard M. Burke, An Historical Chronology of
Tuberculosis, 2nd ed. (Springfield, 111.: Thomas, 1955).
7 For an analysis of the agents and patterns that determine the
epidemic spread of modern misinformation throughout a scientific
community, see Derek J. de Solla Price, Little Science, Big Science
(New York: Columbia Univ. Press, 1963).
8 On the
clerical nature of medical practice, see "Cléricalisme de la fonction
médicale? Médecine et politique. Le 'Sacerdoce' médical. La Relation
thérapeutique. Psychanalyse et christianisme," Le Semeur, suppl. 2
(1966-67).
9J. N. Weisfert, "Das Problem des
Schwindsuchtskranken in Drama und Roman," Deutscher Journalistenspiegel
3 (1927): 579-82. A guide to tuberculosis as a literary motive in
19th-century drama and novel. E. Ebstein, "Die Lungen-schwindsucht in
der Weltliteratur," Zeitschrift für Bücherfreunde 5 (1913).
10 René and Jean Dubos, The White Plague: Tuberculosis, Man and Society
(Boston: Little, Brown, 1953). On the social, literary, and scientific
aspects of 19th-century tuberculosis; an analysis of its incidence.
11 Charles E. Rosenberg, The Cholera Years: The United States in 1832,
1849, and 1866 (Chicago: Univ. of Chicago Press, 1962). The New York
epidemic of 1832 was a moral dilemma from which deliverance was sought
in fasting and prayer. By the time of the epidemics of 1866, the
culture that had produced New York slums had as well produced chloride
of lime.
12 W. J. van Zijl, "Studies on Diarrheal
Disease in Seven Countries," Bulletin of the World Health Organization
35 (1966): 249-61. Reduction in diarrheal diseases is brought about by
a better water supply and sanitation, never by curative intervention.
13 R. R. Porter, The Contribution of the Biological and Medical
Sciences to Human Welfare, Presidential Address to the British
Association for the Advancement of Science, Swansea Meeting, 1971
(London: the Association, 1972), p. 95.
14 N. S.
Scrimshaw, C. E. Taylor, and John E. Gordon, Interactions of Nutrition
and Infection (Geneva: World Health Organization, 1968).
15 John Cassel, "Physical Illness in Response to Stress," Antologia A7,
mimeographed (Cuernavaca: CIDOC [Centro Intercultural de
Documentatión], 1971).
16 One of the clearest early
statements on the paramount importance of the environment is J. P.
Frank, Akademische Rede vom Volkselend als der Mutter der Krankheiten
(Pavia, 1790; reprint ed., Leipzig: Earth, 1960). Thomas McKeown and R.
G. Record, "Reasons for the Decline in Mortality in England and Wales
During the Nineteenth Century," Population Studies 16 (1962): 94-122.
Edwin Chadwick, Report on the Sanitary Condition of the Labouring
Population of Great Britain, 1842, ed. M. W. Flinn (Chicago: Aldine,
1965), concluded a century and a half ago that "the primary and most
important measures and at the same time the most practical, and within
the recognized providence of public administration, are drainage, the
removal of all refuse from habitations, streets, and roads, and the
improvement of the supplies of water." Max von Petterkofer, The Value
of Health to a City: Two Lectures Delivered in 1873, trans. Henry E.
Sigerist (Baltimore: Johns Hopkins, 1941), calculated a century ago the
cost of health to the city of Munich in terms of average wages lost and
medical costs created. Public services, especially better water and
sewage disposal, he argued, would lower the death rate, morbidity, and
absenteeism and this would pay for itself. Epidemiological research has
entirely confirmed these humanistic convictions: Delpit-Morando,
Radenac, and Vilain, Disparités régionales en matière de santé,
Bulletin de Statistique du Ministère de la Santé et de la Sécurité
Sociale No. 3, 1973; Warren Winkelstein, Jr., "Epidemiological
Considerations Underlying the Allocation of Health and Disease Care
Resources," International Journal of Epidemiology 1, no. 1 (1972):
69-74; F. Fagnani, Santé, consommation médicale et environnement:
Problémes et méthodes (Paris: Mouton, 1973).
17 N.
D. McGlashan, ed., Medical Geography: Techniques and Field Studies (New
York: Barnes & Noble, 1973). Jacques May and Donna McLelland, eds.,
Studies in Medical Geography, 10 vols. (New York: Hafner, 1961-71).
Daniel Noin, La Géographic démographique de la France (Paris: PUF,
1973). J. Vallin, La Mortalité en France par tranches depuis 1899
(Paris: PUF, 1973). L. D. Stamp, The Geography of Life and Death
(Ithaca, N.Y.: Cornell Univ. Press, 1965). E. Rodenwaldt et al.,
Weltseuchenatlas (Hamburg, 1956). John Melton Hunter, The Geography of
Health and Disease, Studies in Geography no. 6 (Chapel Hill: Univ. of
North Carolina Press, 1974).
18 Erwin H.
Ackerknecht, Therapeutics: From the Primitives to the Twentieth Century
(New York: Hafner, 1973). A simple overview. J. F. D. Shrewsbury, A
History of the Bubonic Plague in the British Isles (Cambridge:
Cambridge Univ. Press, 1970). An outstanding example of history written
by a bacteriologist and epidemiologist.
19 For an
introduction to the literature, see Steven Polgar, "Health and Human
Behaviour: Areas of Interest Common to the Social and Medical
Sciences," Current Anthropology 3 (April 1962): 159-205. Polgar gives a
critical evaluation of each item and the responses of a large number of
colleagues to his evaluation. See also Steven Polgar, "Health," in
International Encyclopedia of the Social Sciences (1968), 6:330-6;
Eliot Freidson, "The Sociology of Medicine: A Trend Report and
Bibliography," Current Sociology, 1961-62, nos. 10-11, pp. 123-92.
20 Paul Slack, "Disease and the Social Historian," Times Literary
Supplement, March 8, 1974, pp. 233-4. A critical review article.
Catherine Rollet and Agnès Souriac, l'Epidémics et mentalites: Le
Choléra de 1832 en Seine-et-Oise," Annales Economies, Sociétés,
Civilisations, 1974, no. 4, pp. 935-65.
21 Alan
Berg, The Nutrition Factor: Its Role in National Development
(Washington, D.C.: Brookings Institution, 1973). Hans J. Teuteberg and
Günter Wiegelmann, Der Wandel der Nahrungsgewohnheiten unter dm
Einftuss der Industriahsierung (Gottin-gen: Vandenhoeck & Ruprecht,
1972), deal with the impact of industrialization on the quantity,
quality, and distribution of food in 19th-century Europe. With the
transition from subsistence on limited staples to either managed or
chosen menus, the traditional regional cultures of eating, fasting, and
surviving hunger were destroyed. A badly organized rich mine of
bibliographic information. In the wake of Marc Bloch and Lucien Febvre,
some of the most valuable research on the significance of food to power
structures and health levels was done. For an orientation on the method
used, consult Guy Thuillier, "Note sur les sources de 1'histoire
régionale de 1'alimentation au XIXe siècle," Annales Économies,
Sociétés, Civilisations, 1968, no. 6, pp. 1301-19; Guy Thuillier, "Au
XIXe siècle: L'Alimentation en Nivernais," Annales, 1965, no. 6, pp.
1163-84. For a masterpiece consult Fra^ois Lebrun, Les Hommes et la
mart en Anjou au 17' et 18' siecles: Essai de demographie et
psychologic historiques (Paris: Mouton, 1971); A. Poitrineau,
"L'Alimentation populaire en Auvergne au XVIIIe siecle," in Enquêtes,
pp. 323-31. Owsei Temkin, Nutrition from Classical Antiquity to the
Baroque, Human Nutrition Monograph 3, New York, 1962. For the
transformation of bread into a substance machines can produce, see
Siegfried Giedion, Mechanization Takes Command: A Contribution to
Anonymous History (New York: Norton, 1969), especially pts. 4:2, 4:3
(on meat). Also Fernand Braudel, "Le Superflu et 1'ordinaire:
Nourriture et boissons," in Civilisation matérielle et capitalisme
(Paris: Colin, 1967), pp. 134-98.
221. D.
Carruthers, Impact and Economics of Community Water Supply: A Study of
Rural Water Investment in Kenya, Wye College, Ashford, Kent, 1973; on
the impact of water supply on health. On the improvement of rural water
supplies during the 19th century: Guy Thuillier, "Pour une histoire
regionale de 1'eau en Nivernais au XIXe siècle," Annales Économies,
Sociétés, Civilisations, 1968, no. 1, pp. 49 ff. The improvement of
water supplies changed people's attitude towards their own bodies: Guy
Thuillier, "Pour une histoire de l'hygiène corporelle. Un exemple
régional: le Nivernais," Revue d'histoire économique et sociale 46, no.
2 (1968): 232-53; Lawrence Wright, Clean and Decent: The Fascinating
History of the Bathroom and the Water Closet and of Sundry Habits,
Fashions and Accessories of the Toilet, Principally in Great Britain,
France and America (Toronto: Univ. of Toronto Press, 1967). New
patterns for laundry developed: Guy Thuillier, "Pour une histoire de la
lessive au XIXe siècle," Annales, 1969, no. 2, pp. 355-90.
23 Lester B. Lave and Eugene P. Seskin, "Air Pollution and Human
Health," Science 169 (1970): 723-33. Jean-Paul Dessaive et al.,
Médecins, climat et épidémies a la fin du XVIIIe siècle (Paris: Mouton,
1972).
24 A synthetic, well-documented argument to
this point is Emanuel de Kadt, "Inequality and Health," Univ. of
Sussex, January 1975. The original and longer version of this paper was
written in 1972 as the introductory chapter of a book, Saludy
bienestar, which should have been published in Santiago, Chile, in
1973. John Powles, "Health and Industrialisation in Britain: The
Interaction of Substantive and Ideological Change," prepared for a
Colloquium on the Adaptability of Man to Urban Life, First World
Congress on Environmental Medicine and Biology, Paris, July 1-5, 1974.
C. Ferrero, "Health and Levels of Living in Latin America," Milbank
Memorial Fund Quarterly 43 (October 1965): 281-95. A decline in
mortality is not to be anticipated from more expenditures on health
care but from a different allocation of funds within the health sector
combined with social change.
25 Emily R. Coleman,
"L'lnfanticide dans le haul moyen age," trans. A. Chamoux, Annales
Economies, Societes, Civilisations, 1974, no, 2, pp. 315-35. Suggests
that infanticide in the Middle Ages was demographically significant.
Ansley J. Coale, "The Decline of Fertility in Europe from the French
Revolution to World War II," in S. J. Behrman et al., Fertility and
Family Planning (Ann Arbor: Univ. of Michigan Press, 1970). Marital
fertility declined everywhere before the proportion of the population
who married increased. Discrimination against the illegitimate combined
with restricted access to marriage may have served to control
population. This hypothesis is reinforced in J.-L. Flandrin,
"Contraception, mariage et relations amoureuses dans l'Occident
chrètien," Annales, 1969, no. 6, pp. 1370-90. Demographic data suggest
no contraception within marriage for 17th and 18th-century France, but
very low rates of illegitimacy. Contraception in marriage was near
heresy, conception outside marriage a scandal. Flandrin suggests that
during the 19th century sexual behavior between spouses began to be
modeled on traditional behavior outside marriage. Contraception seems
to have become acceptable first among peasant families rich enough to
keep infant mortality low: see M. Leridon, "Fécondité et mortalité
infantile dans trois villages bavarois: Une Analyse de donnees
individualists du XIXe siècle," Population 5 (1969): 997-1002. Although
physicians in England opposed its spread, they seemingly applied it
effectively in their own lives: J. A. Banks, "Family Planning and Birth
Control in Victorian Times," paper read at the Second Annual
Conference, of the Society for the History of Medicine, Leicester
Univ., 1972. The Catholic Church seems to have made contraception an
issue only insofar as it affected the industrial middle classes: see
John Thomas Noonan, Contraception: A History of Its Treatment by the
Catholic Theologians and Canonists (Cambridge: Harvard Univ. Press,
1965). Philippe Aries, "Les Techniques de la mort," in Histoire des
populations françaises et de leurs attitudes devant la vie depuis le
XVIIIe siècle (Paris: Seuil, 1971), p. 373.
26 So
far, world hunger and world malnutrition have increased with industrial
development. "One third to one half of humanity are said to be going to
bed hungry every night. In the Stone Age the fraction must have been
much smaller. This is the era of unprecedented hunger. Now, in the time
of the greatest technical power, starvation is an institution."
Marshall Sahlins, Stone Age Economics (Chicago: Aldine, 1972), p. 23.
27 J. E. Davies and W. F. Edmundson, Epidemiology of DOT (Mount Kisco,
N.Y.: Future, 1972). A good example of paradoxical disease control from
Borneo: Insecticides used in villages to control malaria vectors also
accumulated in cockroaches, most of which are resistant. Geckoes fed on
these, became lethargic, and fell prey to cats. The cats died, rats
multiplied, and with rats came the threat of epidemic bubonic plague.
The army had to parachute cats into the jungle village {Conservation
News, July 1973).
28 A good example of medical
persecution of innovators is given by G. Gortvay and I. Zoltan, I.
Semmelweis, His Life and Work (Budapest: Akademiai Kiado, 1968), a
critical biography of the first gynecologist to use antiseptic
procedures in his wards. In 1848 he reduced mortality from puerperal
fever by a factor of 15 and was thereupon dismissed and ostracized by
his colleagues, who were offended at the idea that physicians could be
carriers of death. Morton Thompson's novel The Cry and the Covenant
(New York: New American Library, 1973) makes Semmelweis come alive.
29 Charles T. Stewart, Jr., "Allocation of Resources to Health,"
Journal of Human Resources 6, no. 1 (1971): 103-21. Stewart classifies
resources devoted to health as treatment, prevention, information, and
research. In all nations of the Western Hemisphere, prevention (e.g.,
potable water) and education are significantly related to life
expectancy, but none of the "treatment variables" are so related.
30 Reuel A. Stallones, in Environment, Ecology, and Epidemiology,
Pan-American Health Organization Scientific Publication no. 231
(Washington, September 30, 1971), shows there is a strong positive
correlation in the U.S.A. between a high proportion of doctors in the
general population and a high rate of coronary disease, while the
correlation is strongly negative for cerebral vascular disease.
Stallones points out that this says nothing about a possible influence
of doctors on either. Morbidity and mortality are an integral part of
the human environment and unrelated to the efforts made to control any
specific disease.
31 Alain Letourmy and François
Gibert, Santé, envirmnemmt, consommations médicales: Un Modèle et son
estimation à partir des donneés de mortalité; Rapport principal (Paris:
CEREBE (Centre de Recherche sur le Bien-etre), June 1974). Compares
mortality rates in different regions of France; they are unrelated to
medical density, highly related to the fat content of the sauces
typical of each region, and somewhat less to alcohol consumption.
32 The model study on this matter at present seems to be A. L.
Cochrane, Effectiveness and Efficiency: Random Reflections on Health
Services, Nuffield Provincial Hospitals Trust, 1972. See also British
Medical Journal, 1974, 4:5. A. Querido, Efficiency of Medical Care (New
York: International Publications, 1963).
33 Jacques
M. May, "Influence of Environmental Transformation in Changing the Map
of Disease," in M. Taghi Farvar and John P. Milton, eds., The Careless
Technology (Garden City, N.Y.: Natural History Press, 1972), pp. 19-34.
May warns that mosquito resistance to insecticides on the one hand and
parasite resistance to chemotherapeutic agents on the other may have
created an unanswerable challenge to human adaptation.
34 Henry J. Parish, A History of Immunization (Edinburgh: Livingstone,
1965). Consult historical introduction for literature. The
effectiveness of prevention in relation to any specific disease must be
distinguished from its contribution to the volume of disease: J. H.
Alston, A New Look at Infectious Disease (London: Pitman, 1967), shows
how infections are replaced by new ones, without reduction in over-all
volume. Keith Mellanby, Pesticides and Pollution (New York: Collins,
1967), in an easily understandable way demonstrates how the engineering
mechanisms designed to reduce one infection foster others.
35 República de Cuba, Ministerio de la Salud Pública, Cuba:
Organizacion de los servicios y nivel de salud (Havana, 1974),
introduction by Fidel Castro. An impressive demonstration of the shift
in mortality and morbidity patterns over one decade, during which major
infections on the whole island were significantly affected by a
public-health campaign. Nguyen Khac Vien, "25 Anneés d'activites
médico-sanitaires," Études vietnamiennes (Hanoi), no. 25, 1970.
36 G. O. Sofoluwe, "Promotive Medicine: A Boost to the Economy of
Developing Countries," Tropical and Geographical Medicine 22 (June
1970): 250-4. During the 30 years between 1935 and 1968, most curative
measures used for parasitic diseases and infections of the skin and
respiratory organs and for diarrhea have left "the pattern of morbidity
on the whole unchanged."
37 In Farvar and Milton,
eds., The Careless Technology, several authors make this point
specifically for malaria, Bancroftian filariasis (Hamon),
schistosomiasis (van der Schalie), and genito-urinary infections
(Farvar).
38Bruce Mitchel, Fluoridation
Bibliography, Council of Planning Librarians Exchange Bibliography no.
268 (Waterloo, Ont., March 1972). Covers the debate and especially the
social scientist's perception of people's behavior regarding
fluoridation in Canada.
39 C. L. Meinert et al., "A
Study of the Effects of Hypoglycemic Agents on Vascular Complications
in Patients with Adult-Onset Diabetes. II. Mortality Results, 1970,"
Diabetes 19, suppl. 2 (1970): 789-830. G. L. Knatterud et al., "Effects
of Hypoglycemic Agents on Vascular Complications in Patients with
Adult-Onset Diabetes," Journal of the American Medical Association 217
(1971): 777-84. Cochrane, Effectiveness ana" Efficiency, comments on
the last two. They suggest that giving tolbutamide and phenformin is
definitely disadvantageous in the treatment of mature diabetics and
that there is no advantage in giving insulin rather than a diet.
40 H. Oeser, Krebsbekämpfung: Hoffnung and Realität (Stuttgart: Thieme,
1974). This is so far, to my knowledge, the most useful introduction
for the general physician or layman to a critical evaluation of world
literature on the effectiveness of cancer treatment. See also N. E.
McKinnon, "The Effects of Control Programs on Cancer Mortality,"
Canadian Medical Association Journal 82 (1960): 1308-12. K. T. Evans,
"Breast Cancer Symposium: Points in the Practical Management of Breast
Cancer. Are Physical Methods of Diagnosis of Value?" British Journal of
Surgery 56 (1969): 784-6.
41 Edwin F. Lewison, "An
Appraisal of Long-Term Results in Surgical Treatment of Breast Cancer,"
Journal of the American Medical Association 186 (1963): 975-8. "The
most impressive feature of the surgical treatment of breast cancer is
the striking similarity and surprising uniformity of long-term end
results despite widely differing therapeutic techniques as reported
from this country and abroad." The same can be said today.
42 Robert Sutherland, Cancer: The Significance of Delay (London:
Butterworth, 1960), pp. 196-202. Also Hedley Atkins et al., "Treatment
of Early Breast Cancer: A Report after Ten Years of Clinical Trial,"
British Medical Journal, 1972, 2:423-9; also p. 417. D. P. Byar and
Veterans Administration Cooperative Urological Research Group,
"Survival of Patients with Incidentally Found Microscopic Cancer of the
Prostate: Results of Clinical Trial of Conservative Treatment," Journal
of Urology 108 (December 1972): 908-13. Random comparison of four
treatments (placebo, estrogen, placebo and orchiectomy, and estrogen
and orchiectomy) reveals no significant differences among them, nor in
comparison with radical prostatectomy. For a broad survey of analogous
research on cancer in various sites, see note 40 above.
43 Ann G. Kutner, "Current Status of Steroid Therapy in Rheumatic
Fever," American Heart Journal 70 (August 1965): 147-9. Rheumatic Fever
Working Party of the Medical Research Council of Great Britain and
Subcommittee of Principal Investigators of the American Council on
Rheumatic Fever and Congenital Heart Disease, American Heart
Association, "Treatment of Acute Rheumatic Fever in Children: A
Cooperative Clinical Trial of ACTH, Cortisone and Aspirin," British
Medical Journal, 1955, 1:555-74.
44 Albert N.
Brest, "Treatment of Coronary Occlusive Disease: Critical Review,"
Diseases of the Chest 45 (January 1964): 40-45. Malcolm I. Lindsay and
Ralph E. Spiekerman, "Re-evaluation of Therapy of Acute Myocardial
Infarction," American Heart Journal 67 (April 1964): 559-64. Harvey D.
Cain et al., "Current Therapy of Cardiovascular Disease," Geriatrics 18
(July 1963): 507-18.
45 H. G. Mather et al., "Acute
Myocardial Infarction: Home and Hospital Treatment," British Medical
Journal, 1971, 3:334-8.
46 Combined Staff Clinic, "Recent Advances in Hypertension," American Journal of Medicine 39 (October 1965): 634-8.
47 For some of the standard textbooks see Robert H. Moser, The Disease
of Medical Progress: A Study of Iatrogmic Disease, 3rd ed.
(Springfield, 111.: Thomas, 1969). David M. Spain, The Complications of
Modem Medical Practices (New York: Grune & Stratton, 1963). H. P.
Kümmerle and N. Goossens, Klinik und Therapie der Nebenwirkungen
(Stuttgart: Thieme, 1973 [1st ed., I960]). R. Heintz, Erkrankungen
durch Arzneimittel: Diagnostik, Klinik, Patkogenese, Therapie
(Stuttgart: Thieme, 1966). Guy Duchesnay, Le Risque therapeutique
(Paris: Doin, 1954). P. F. D'Arcy and J. P. Griffin, Iatrogenic Disease
(New York: Oxford Univ. Press, 1972).
48 For the
evolution of jurisprudence related to this kind of torts see M. N.
Zald, "The Social Control of General Hospitals," in B. S. Georgopoulos,
ed., Organization Research on Health Institutions (Ann Arbor: Univ. of
Michigan, Institute for Social Research, 1972). See also Angela Holder,
Medical Malpractice Law (New York: Wiley, 1974).
49
Such side-effects were studied by the Arabs. Al-Razi (A.D. 865-925),
the medical chief of the hospital of Baghdad, was concerned with the
medical study of iatrogenesis, according to Al-Nadim in the Fihrist,
chap. 7, sec. 3. At the time of Al-Nadim (A.D. 935), three books and
one letter of Al-Razi on the subject were still available: The Mistakes
in the Purpose of Physicians; On Purging Fever Patients Before the Time
Is Ripe; The Reason Why the Ignorant Physicians, the Common People, and
the Women in Cities Are More Successful Than Men of Science in Treating
Certain Diseases and the Excuses Which Physicians Make for This; and
the letter: "Why a Clever Physician Does Not Have the Power to Heal All
Diseases, for That Is Not Within the Realm of the Possible."
50 See also Erwin H. Ackerknecht, "Zur Geschichte der iatrogenen
Krankhei-ten," Gesnerus 27 (1970): 57-63. He distinguishes three waves,
or periods, since 1750 when the study of iatrogenesis was considered
important by the medical establishment. Erwin H. Ackerknecht, "Zur
Geschichte der iatrogenen Erkrankungen des Nervensystems,"
Therapeutische Umschau/Revue thérapeutique 27, no. 6 (1970): 345-6. A
short survey of medical awareness of the side-effects of drugs on the
central nervous system, starting with Avicenna (980-1037) on mercury.
51 L. Meyler, Side Effects of Drugs (Baltimore: Williams & Wilkins,
1972). Adverse Reactions Titles, a monthly bibliography of titles from
approximately 3,400 biomedical journals published throughout the world;
published in Amsterdam since 1966. Allergy Information Bulletin,
Allergy Information Association, Weston, Ontario.
52 P. E. Sartwell, "Iatrogenic Disease: An Epidemiological
Perspective," International Journal of Health Services 4 (winter 1974):
89-93.
53 Pharmaceutical Society of Great Britain,
Identification of Drugs and Poisons (London: the Society, 1965).
Reports on drug adulteration and analysis. Margaret Kreig, Black Market
Medicine (Englewood Cliffs, N.J.: Prentice-Hall, 1967), reports that an
increasing percentage of articles sold by legitimate professional
pharmacies are inert counterfeit drugs indistinguishable in packaging
and presentation from the trademarked product.
54
Morton Mintz, By Prescription Only, 2nd ed. (Boston: Beacon Press,
1967). (For a fuller description of this book, see below, note 98, p.
67.) Solomon Garb, Undesirable Drug Interactions, 1974-75, rev. ed.
(New York: Springer, 1975). Includes information on inactivation,
incompatibility, potentiation, and plasma binding, as well as on
interference with elimination, digestion, and test procedures.
55 B. Opitz and H. Horn, "Verhutung iatrogener Infektionen bei
Schutzimpfungen," Deutsches Gesundheitswesen 27/24 (1972): 1131-6. On
infections associated with immunization procedures.
56 Harry N. Beaty and Robert G. Petersdorf, "Iatrogenic Factors in
Infectious Disease," Annals of Internal Medicine 65 (October 1966):
641-56.
57 Every year a million people—that is, 3
to 5 percent of all hospital admissions—are admitted primarily because
of a negative reaction to drugs. Nicholas Wade, "Drug Regulation: FDA
Replies to Charges by Economists and Industry," Science 179 (1973):
775-7.
58 Eugene Vayda, "A Comparison of Surgical
Rates in Canada and in England and Wales," New England Journal of
Medicine 289 (1973): 1224-9, shows that surgical rates in Canada in
1968 were 1.8 times greater for men and 1.6 times greater for women
than in England. Discretionary operations such as tonsillectomy and
adenoidectomy, hemorroidectomy, and inguinal herniorrhaphy were two or
more times higher. Cholecystectomy rates were more than five times
greater. The main determinants may be differences in payment of health
services and available hospital beds and surgeons. Charles E. Lewis,
"Variations in the Incidence of Surgery," New England Journal of
Medicine 281 (1969): 880-4, finds three- to fourfold variations in
regional rates for six common surgical procedures in the U.S.A. The
number of surgeons available was found to be the significant predictor
in the incidence of surgery. See also James C. Doyle, "Unnecessary
Hysterectomies: Study of 6,248 Operations in Thirty-five Hospitals
During 1948," Journal of the American Medical Association 151 (1953):
360-5. James C. Doyle, "Unnecessary Ovariectomies: Study Based on the
Removal of 704 Normal Ovaries from 546 Patients," Journal of the
American Medical Association 148 (1952): 1105-11. Thomas H. Weller,
"Pediatric Perceptions: The Pediatrician and latric Infectious
Disease," Pediatrics 51 (April 1973): 595-602.
59
Clifton Meador, "The Art and Science of Nondisease," New England
Journal of Medicine 272 (1965): 92-5. For the physician accustomed to
dealing only with pathologic entities, terms such as "nondisease
entity" or "nondisease" are foreign and difficult to comprehend. This
paper presents, with tongue in cheek, a classification of nondisease
and the important therapeutic principles based on this concept.
Iatrogenic disease probably arises as often from treatment of
nondisease as from treatment of disease.
60 Abraham
B. Bergman and Stanley J. Stamm, "The Morbidity of Cardiac Nondisease
in School Children," New England Journal of Medicine 276 (1967):
1008-13. Gives one particular example from the "limbo where people
either perceive themselves or are perceived by others to have a
nonexistent disease. The ill effects accompanying some nondiseases are
as extreme as those accompanying their counterpart diseases . . . the
amount of disability from cardiac nondisease in children is estimated
to be greater than that due to actual heart disease." See also J.
Andriola, "A Note on Possible Iatrogenesis of Suicide," Psychiatry 36
(1973): 213-18.
61 Clinical iatrogenesis has a long
history. Plinius Secundus, Naturalis Historia 29.19: "To protect us
against doctors there is no law against ignorance, no example of
capital punishment. Doctors learn at our risk, they experiment and kill
with sovereign impunity, in fact the doctor is the only one who may
kill. They go further and make the patient responsible: they blame him
who has succumbed." In fact, Roman law already contained some
provisions against medically inflicted torts, "damnum injuria datum per
medicum." Jurisprudence m Rome made the doctor legally accountable not
only for ignorance and recklessness but for bumbling. A doctor who
operated on a slave but did not properly follow up his convalescence
had to pay the price of the slave and the loss of the master's income
during his protracted sickness. Citizens were not covered by these
statutes, but could avenge malpractice on their own initiative.
62 Montesquieu, De I'esprit des lois, bk. 29, chap. 14, b (Paris:
Pléiade, 1951). The Roman laws ordained that physicians should be
punished for neglect or lack of skill (the Cornelian laws, De Sicariis,
inst. iv. tit. 3, de lege Aquila 7). If the physician was a person of
any fortune or rank, he was only condemned to deportation, but if he
was of low condition he was put to death. In our institutions it is
otherwise. The Roman laws were not made under the same circumstances as
ours: in Rome every ignorant pretender meddled with physic, but our
physicians are obliged to go through a regular course of study and to
take degrees, for which reason they are supposed to understand their
profession. In this passage the 17th-century philosopher demonstrates
an entirely modern optimism about medical education.
63 For German internists, the time the patient can spend face-to-face
with his doctor has now been reduced to 1.7 minutes per visit. Heinrich
Erdmann, Heinz-Giinther Overrath, and Wolfgang and Thure Uxkull,
"Organisationspro-bleme der ärztlichen Krankenversorgung: Dargestellt
am Beispiel einer mediz-inischen Universitatsklinik," Deutsches
Ärzteblatt-Ärztliche Mitteilungm 71 (1974): 3421-6. In general
practice, this time was (in 1963) about 3 minutes. See T. Geyer,
Verschwörung (Hilchenbach: Medizinpolitischer Verlag, 1971), p. 30.
64 For the broader issue of genetic rather than individual damage, see
John W. Goffinan and Arthur R. Tamplin, "Epidemiological Studies of
Carcinogenesis by Ionizing Radiation," in Proceedings of the Sixth
Berkeley Symposium on Mathematical Statistics and Probability, Univ. of
California, July 1970, pp. 235-77. The presumption is all too common
that where uncertainty exists about the magnitude of carcinogenic
effects, it is appropriate to continue the exposure of humans to the
risk. The authors show that it is neither appropriate nor good
public-health practice to demand human epidemiological evidence before
stopping exposure. The argument against ionizing radiation from nuclear
generation of electrical energy can be applied to all medical treatment
in which there is uncertainty about genetic impact. The competence of
physicians to establish levels of tolerance for entire populations must
be questioned on theoretical grounds.
65 For data
and further bibliography see U.S. House of Representatives, Committee
on Interstate and Foreign Commerce, An Overview of Medical Malpractice,
94th Cong., 1st Sess., March 17, 1975.
66 The
maltreatment of patients has become an accepted routine; see Charles
Butterworth, "Iatrogenic Malnutrition," Nutrition Today, March-April
1974. One of the largest pockets of unrecognized malnutrition in
America and Canada exists, not in rural slums or urban ghettos, but in
the private rooms and wards of big-city hospitals. J. Mayer,
"Iatrogenic Malnutrition," New England Journal of Medicine 284 (1971):
1218.
67 George H. Lowrey, "The Problem of Hospital Accidents to Children," Pediatrics 32 (December 1963): 1064-8.
68 J. T. McLamb and R. R. Huntley, "The Hazards of Hospitalization,"
Southern Medical Journal 60 (May 1967): 469-72.
69
"La maladie iatrogène est presque toujours a base névrotique": L.
Israel, "La Maladie iatrogène," in Doamenta Sandoz, n.d.
70 The distinction of several levels of iatrogenesis was made by Ralph
Audy, "Man-made Maladies and Medicine," California Medicine, November
1970, pp. 48-53. He recognizes that iatrogenic "diseases" are only one
type of man-made malady. According to their etiology, they fall into
several categories: those resulting from diagnosis and treatment, those
relating to social and psychological attitudes and situations, and
those resulting from man-made programs for the control and eradication
of disease. Besides iatrogenic clinical entities, he recognizes other
maladies that have a medical etiology.
71 "Das
Schicksal des Kranken verkorpert als Symbol das Schicksal der
Menschheit im Stadium einer technischen Weltentwicklung": Wolfgang
Jacob, Der kranke Mensch in der technischen Welt, IX. Internationaler
Fortbildungskurs fur praktische und wissenschaftliche Pharmazie der
Bundesapothekerkammer in Meran (Frankfurt am Main: Werbe- und
Vertriebsgesellschaft Deutscher Apotheker, 1971).
72 James B. Quinn, "Next Big Industry: Environmental Improvement,"
Harvard Business Review 49 (September-October 1971): 120-30. He
believes that environmental improvement is becoming a dynamic and
profitable series of markets for industry that pay for themselves and
in the end will represent an important addition to income and GNP.
Implicitly the same argument is being made for the health-care field by
the proponents of no-fault malpractice insurance.
73 The term was used by Honoré Daumier (1810-79). See reproduction of
his drawing "Nemesis medicale" in Werner Block, Der Artzt und der Tod
in Bildem aus seeks Jahrhunderten (Stuttgart: Enke, 1966).