• DOI:10.7326/0003-4819-126-2-199701150-00012
• Corpus ID: 32352763

The Pre-Flexnerian Reports: Mark Twain's Criticism of Medicine in the United States

@article{Ober1997ThePR,
  title={The Pre-Flexnerian Reports: Mark Twain's Criticism of Medicine in the United States},
  author={Patrick Ober},
  journal={Annals of Internal Medicine},
  year={1997},
  volume={126},
  pages={157-163}
}

• Patrick Ober
• Published 15 January 1997
• Medicine
• Annals of Internal Medicine

The year 1910 is remembered for the long-predicted return of Halley's comet, the death of Mark Twain, and the publication of Abraham Flexner's famous treatise, Medical Education in the United States and Canada. The Flexner report criticized the medical education of its era as a loose and poorly structured apprenticeship system that generally lacked any defined standards or goals beyond the generation of financial profit [1]. Medical education eventually developed into a formalized scientific discipline within the framework of the traditional university system [2, 3] as a result of numerous social and political forces. The Flexner report has probably been given undue credit for this reformation, although its publication in 1910 serves as a helpful milestone for charting the evolution of medicine in the United States. A unique and useful perspective on pre-Flexnerian U.S. medicine can be found in the words of Mark Twain (Samuel Clemens), the famous author and social critic [4, 5]. Although Twain's commentaries on medical practice are not as famous as his remarks on Halley's comet (the comet's appearance in 1835 coincided with his birth and inspired Twain to predict, correctly, that he would go with Halley's comet when it returned in 1910 [[6]), his assessment of the medicine of his era provides a fresh, humanistic, and personalized view of the state of medicine in the United States before the formal commentary of Flexner. Medicine as Humor, Satire, and Burlesque Twain's comments on medicine and physicians were complex and served various purposes. The author used his own childhood experiences with the medical care of the American frontier (which included folk medicine, quackery, and snake oil remedies) to add color to his fiction. He made other statements to provide a stage for medical burlesque, pure and simple. As in much of his writing, criticism and humor were often intertwined in his medical observations. As Friedlander discussed in 1972 [4], Twain respected and trusted individual physicians but was cynical about medical practitioners collectively. The ineffectiveness of medical therapy was a recurring theme in Twain's work; for example, it appears in his suggestion that the natural course of an illness might be preferable to its treatment [7]: During Monday, Tuesday and Wednesday the twins grew steadily worse; but then the doctor was summoned south to attend his mother's funeral and they got well in forty-eight hours. In a 1909 speech to the New York Postgraduate Medical School, Twain was introduced as Dr. Samuel L. Clemens, and he took advantage of the honorary medical degree to observe that I am glad to be among my own kind tonight. I was once a sharpshooter, but now I practice a much higher and equally as deadly a profession [8]. Twain ridiculed stereotypical features of physicians, including illegible handwriting which from the beginning of time has been so disastrous to the apothecary and so profitable to the undertaker [7]. Similarly, Twain's satire attacked the pretentiousness of medical jargon by quoting a fictional physician [7] who was considered by long odds the most learned physician in the town, and quite well aware of it: Without going too much into detail, madam-for you would probably not understand it anyway-I concede that great care is going to be necessary here; otherwise exudation of the aesophagus is nearly sure to ensue, and this will be followed by ossification and extradition of the maxillaris superioris, which must decompose the granular surfaces of the great infusorial ganglionic system, thus, obstructing the action of the posterior varioloid arteries and precipitating compound strangulated sorosis of the valvular tissues, and ending unavoidably in the dispersion and combustion of the marsupial fluxes and the consequent embrocation of the bicuspid populo redax referendum rotulorum. Twain directed further sarcasm at the medical profession's unquestioning reliance on unproven treatments handed down from practitioner to practitioner. In 1890, in A Majestic Literary Fossil, he lampooned a text that he identified as the Dictionary of Medicine (actually titled A Medicinal Dictionary; Including Physic, Surgery, Anatomy, Chymistry, and Botany). Published in 1743 by the fashionable English physician Dr. Robert James, this book was still used by practitioners well into the 19th century [9-11]. It recommended such practices as the bleeding of patients with leeches, venesection, and arteriotomy; death was a common outcome. Medicine in the United States in the 1800s: Folklore, Faith Healing, and the Failings of Traditional Medicine Twain recognized that patients in the United States in the 1800s had many options regarding medical care, including treatment by practitioners who had no formal medical education. Doctors were not called in cases of ordinary illness; the family grandmother attended to those. Every old woman was a doctor and gathered her own medicines in the woods and knew how to compound doses that would stir the vitals of a cast-iron dog. And then there was the Indian doctor; a grave savage, remnant of his tribe, deeply read in the mysteries of nature and the secret properties of herbs; and most backwoodsmen had high faith in his powers and could tell of wonderful cures achieved by him [12]. Patent medicines were readily available to the average citizen of Twain's day. As a youngster, Clemens was exposed to many popular patent medicines at the hands of his mother, who eagerly embraced any type of treatment that was in fashion: She bought any patent medicine that came along, whether she would need it or not, and would try any disease that happened to be around. She experimented on me [13]. When home remedies and patent medicines failed, patients had the option of seeking care from a practitioner of allopathic medicine. As a youth, Twain had considerable exposure to this branch of medical care: I was always told that I was a sickly and precarious and tiresome and uncertain child and lived mainly on allopathic medicines during the first seven years of my life [12]. However, little evidence indicated that orthodox medicine was an improvement over the other choices [14]. Allopathic medicine was based on the use of agents that were believed to be incompatible with the effects of the disease being treated [15]; it became a system of aggressive therapy that used intensive pharmacologic treatment and bloodletting [14]. In a letter written in 1900 [4], Twain reflected on the medical practices of his earlier years as he criticized the physician's grotesque system-the emptying of miscellaneous and harmful drugs into a person's stomach to remove ailments which in many cases the drugs could not reach at all; in many cases could reach and help, but only at cost of damage to some other part of the man; and in the remainder of the cases the drug either retarded the cure, or the disease was cured by nature in spite of the nostrums. Twain expressed contempt for the illogical allopathic treatments that had become the standards of his day [12]. Castor oil was the principal beverage. The dose was half a dipperful, with half a dipperful of New Orleans molasses added to help it down and make it taste good, which it never did. The next standby was calomel; the next rhubarb; and the next jalap. Then they bled the patient and put mustard plasters on him. It was a dreadful system and yet the death rate was not heavy. Nineteenth century medicine was as stagnant as it was toxic; therapeutic bloodletting had been championed in James' Medicinal Dictionary of 1743, and it was still being strongly advocated in 1892 by William Osler [16]. Twain told the Society of Medical Jurisprudence in 1902 [17] that a sort of medicine I used to take myself fifty years ago was in use also in the time of the Pharaohs, and all the knowledge up to fifty years ago you got from five thousand years before that Medicine was like astronomy, which did not move for centuries. Twain expressed similar criticisms in his fictional works. In Those Extraordinary Twins [7], he observed that Galen was still the only medical authority recognized in Missouri; his practice was the only practice known to the Missouri doctors, and his prescriptions were the only ammunition they carried when they went out for game. Given the obvious shortcomings of the orthodox medicine of the 1800s, it is not surprising that other methods of medical care arose; almost two dozen competing medical systems were in use by the 1840s [18]. One of the more popular, hydrotherapy, was based on the presumed therapeutic properties of water [15, 18]. In its many variations, it encompassed prolonged bathing in spas, intensive drinking of water, and the promotion of sweating (the aqueous analogy of purging and bleeding as a method for evacuating disease processes). A common treatment was to wrap the patient in sheets dipped in cold water, cover him in woolen blankets, throw him into a feather bed until profuse perspiration developed, and then unwrap him and pour cold water over him [15]. Young Samuel Clemens had personal experience with this alternative to allopathic medicine [13]. I can remember well when the cold water cure was first talked about. I was then about nine years old, and I remember how my mother used to stand me up naked in the back yard every morning and throw buckets of cold water on me, just to see what effect it would have. Personally, I had no curiosity upon the subject. And then, when the dousing was over, she would wrap me up in a sheet wet with ice water and then wrap blankets around that and put me into bed. I never realized that the treatment was doing me any particular good physically. But it purified me spiritually. For pretty soon after I was put into bed I would get up a perspiration that was something worth seeing. The failures of medicine in all of its forms served to promote a niche for faith healing in frontier America in the 1800s. Twain's mother con