Charles Ross

Advanced Writing for Research

Prof. Jean Timberlake

February 16, 1999

A man is wasting away and his family has grown concerned. They summon their family doctor and though he makes few house calls, he agrees to stop by. They talk for some time about how things are going, when the man first felt poorly, what he’s been eating and the like. There is a treatment that the doctor prescribes, "I have heard this medicine helped a patient of one of my fellow doctors in another town." "Which doctor was that?" "Why Dr X, do you know him?" "Yes, he’s a good doctor, I’ve heard." Sure enough, in a week or so when the doctor sees him out walking, the man is nearly himself. A year later he is completely fine.

In another place, a young woman is having similar difficulties. She is living on her own and she goes to see the doctor recommended by her employer. The doctor listens to her problems and says he recognizes the kind of syndrome she is describing. "You have what we call a neurochemical imbalance. There is a treatment that has been proven very successful in trials – it’s the latest advance." "It takes several weeks before you will notice, though." "Oh," she replies, "I know someone who is using that – she says it’s changed her life!" The doctor smiles. In a month she does feel better. A year later she is still doing OK and visits the doctor’s office every month, but has started drinking quite a bit more than before. She has not mentioned this to the doctor and perhaps she never will because it is none of his business. This woman is like someone you may know. So is the old man, but he lived several thousand years ago - or maybe only a hundred, in some place where doctors are lifelong neighbors and medicines come from plants grown a short walk away.

The doctor of ancient times relied on his own personal experience and the teachings of his elders for knowledge of illness and cure. His patients trusted him because they grew up living alongside their doctor. They also had personal familiarity with most of the plants and tools used by their healers. It is no longer this way. Neither the patient nor the doctor of today is physically familiar with the medicines prescribed – the physician relies largely on recommendations provided by papers the medicine vendor has printed. The pharmaceutical industry has co-opted a key social role that was once played by tribal healers. People with health problems in modern communities are in many cases not being served as well as their ancestors because of this and three associated cultural changes.

The role of the healer may be one of the oldest callings known to humanity. In fact, there is evidence that this is a part played by one creature toward another among our biological ancestors. In the first chapter of his beautifully designed book The Healing Hand, Guido Majno describes several observations of chimpanzees in captivity who felt compelled to treat their inmates for abscessed wounds, objects in the eye and even to practice dentistry. He quotes one naturalist who, observing that that chimps like to remove splinters from each other, offered his own splintered finger to a simian friend. The operation, although a little painful, was a success with no payment demanded (8).

If we are to give a general sweep to the role of healers in the history of humanity, we must realize that there has been a different story in each region of the world, with cultures both intermixing and growing (or declining) in isolation from each other. I will focus on the historical role of healing practices as I can find their influence in American society at the end of the twentieth century AD. This means an emphasis on the traditions of the west – easily done since the research literature available to an English speaker has this emphasis built in.

The major roots of western healing practices can be generalized to several sources; folk practices of preliterate societies, the medicine of Egyptian and Mesopotamian Antiquity, the medicine of Classical Greece and Rome, some influences from Arabic and Oriental cultures, the social reforms of the Enlightenment, and the discovery of germs as a cause of disease barely more than 100 years ago. The most important feature of this historical landscape is that from the time of ancient Egypt to the time of Louis Pasteur, very little progress was made in the medical arts. Some might argue that in the West, medicine had even started going downhill at that point in history. What little progress happened was mostly accumulated practical wisdom, both of doctors and of the folk variety, as well as some cultural changes in the structure of commerce, such as the appearance of professional pharmacists.

It is likely that early humans banded together by their very nature and as the rudiments of language and culture took hold, one of the earliest specialties would have been the cultivation of remedies and cures. Most researchers into preliterate societies agree that the healing role was mixed with that of the magician and of the spirit guide in the person of a tribal shaman. The shaman might be a wise man or woman who usually had felt a calling to the position as a youth, with some apprenticeship and a ritual initiation into the practice.

The knowledge of common remedies was not kept secret since often the cure came in the form of "go to the grove of Kooklacht trees in the middle of the forest and pick one of the furry leaves from the plants that grow beneath them. Chew on those and your stomach will feel better soon." These remedies were common knowledge to primitive folk, as today we know what color bottle or tube to fetch from the aisles of the local drugstore for many common ills. As more dire and rare illnesses came to be encountered and remembered, so the craft of the healer became a matter of extensive training and responsibility for the lore of generations.

A good healer knew her local history and geography as well as the history and circumstances of all her tribemates. As long as tribes did not move too far, the local plant life was well understood as a source for many medicinal items. There were undoubtedly some tricks of the trade that involved showmanship, counseling and bargaining with other important members of their own or neighboring tribes. The perceived value of tribal medicine knowledge has increased in recent decades, just as the indigenous tribes and their lands (most notably the rainforests) have been reduced to a trace of what existed a hundred years ago. One example of such a loss is recounted by Robin Hanbury-Tennison in his memoir A World Apart. He went on a trip up the Ventuari River in Brazil in search of a plant with reputed blood-clotting properties. When his party found a group of Piaora, a tribe said to use this plant, it turned out they had missed the shaman by a few months. The government had sent out a medical worker with pills to fight some of the new diseases the tribe had been exposed to, but

Hunter-gatherer people are now being recognized as "walking encyclopedias" of regional biological knowledge (Diamond 143), a human resource only renewable through apprenticeship and experience.

As some tribes moved from hunting and gathering into the agricultural mode of living (starting around 12,000 to 10,000 BC in Mesopotamia and around the Mediterranean, known to students of that time as the Neolithic period), the amount and nature of their roles in life changed in kind. The division of life’s duties into trades and professions had progressed and tribal wise persons were replaced by specialists of various kinds. As agriculture rose, so did full-scale war and slavery, so the folkways of some people would be merged with others or in some cases, passed on secretly. While there is no agreement on a certain series of cultural stages or that the ways of contemporary indigenous people can be assumed to be the same as those who practiced medicine before the first writing appeared, some broad patterns are apparent. One of the new specialties would be designated as "magician," "sorcerer" or "witch," which might simply be the label attached to those whose particular methods (or invoked gods) had gone out of favor. For the dominant group, most anthropology writers seem to agree that there was in advanced societies at least a division of roles between the physician and the priest (Inglis 45). Earlier farming settlements left fewer clues, but it is known, for instance that the Pueblo people, who had a somewhat "less advanced" culture (though much more recent) than Old Kingdom Egypt had "healing societies" who worked in groups (Wolfson 57). Some early records of medicine are lists of symptoms and treatments from the Egyptians and the Babylonians. The Code of Hammurabbi included laws concerned with surgical fees and with malpractice compensation. For saving a noble’s life with surgery, a physician deserved ten shekels (about a year’s pay for a craftsman), for losing his patient, he lost his hand (Porter 46). Another pattern that appears broadly across time and place is an order of resort for the person with a medical complaint.

1. Try to find your own remedy or ask Grandma.
2. Ask the local remedy merchant (barber, druggist, root-gatherer etc…).
3. Go to the doctor.
4. Go to the priest.

Also discernable over the millennia is that there have been occasional turf wars, alternating with partnerships, between members of last three levels of this hierarchy.

The Egyptians had an elaborate medical system which divided duties among priests, magicians and physicians. Their methods could overlap, with magicians issuing potions to exorcise demons and with doctors voicing incantations along with their treatments. The physicians were divided into specialties for all parts of the body, but most were generalists. There was a chief medical officer for the kingdom and a complete hierarchy that included Inspectors and at the fourth level, Physicians. There was not yet a distinction between physician and pharmacist (Casson 65). The skill of Egyptian doctors as well as their pharmacy was renowned for centuries all around the Mediterranean. The materia medica of the Greeks and of Galen was largely based on items from the Egyptian formulary.

The Greeks were the next major civilization to have an influence on contemporary western medicine. Their influence was more on the culture and lore of medicine than in any scientific advance, though the Greek philosophers came to influence science itself, which came around as another medical influence after a few intervening centuries. There was a Greek physician named Asklepios who lived around 1000 BC who developed a very good reputation. He was talked about in legend for hundreds of years (his legendary teacher was the centaur Chiron) and was deified as a son of Apollo, with his three children, Hygeia, Panacea and Telesphoros (Shelton 25). Hygeia was the goddess of health, still known by our word hygiene and Panacea’s name meant "cure-all" – still used but less often associated with medicine. Telesphoros was associated with recovery and is rarely invoked in spite of the popularity of the recovery movement. The Hippocratic oath begins with this family unit, "I swear by Apollo the healer, by Asklepios, by Health (Hygeia) and all the powers of healing (Panacea), and call to witness all the gods and goddesses… (Porter 98)."

The Greek medical approach was essentially also split between the physician and the priest, with the temples of Asklepios serving as centers for healing by spiritual means and the school of Hippocrates striving to find secular cures, based on a natural philosophy, which developed about a hundred years after the cult of Asklepios. The physicians might also be regulars at the temples, even priests – "complementary" medicine is nothing new after all – in fact it has been ventured that Hippocrates was an Asklepian priest, perhaps one who became disenchanted. Unlike the Egyptian doctors, who were employed by temples and state enterprise, Greek physicians were free practitioners, bound together if at all only by a type of fellowship that was a precursor to modern guilds and other organizations. So far as limits to the of art and science of healing, there were few advances made for 2 millennia after the philosophy of Hippocrates. The Roman doctor Galen made his mark in the second century AD and his works of consolidation, largely in the Hippocratic tradition, remained the standard for over a thousand years in Europe. There were practitioners faithful to the theories of Galen even at the time of Pasteur, and with some very sympathetic alternative practitioners, there may yet be a few holdouts!

From ancient times, there had been a difference between the trade of the physician and that of the surgeon, more marked in some cultures than others. In the Roman Empire, a surgeon was less studied than a physician, often a kind of shop mechanic for slaves and gladiators. Galen first gained fame as a talented gladiator body-repairman in Alexandria during the second century AD (Griggs 14). His skill and personal dynamism were such that he came to be the personal physician to Marcus Aurelius and several of his successors. Galen managed to compile the teachings of Hippocrates and many others into a convincing and well-explained medical system that would be nearly unchallenged by experiment or theory until the Reformation. One solid reason offered (Griggs 15) for this grand ossification of thought is that he consolidated his system at exactly the same time that Rome began its decline, and the physicians, lovers of learning and tradition, clung to this vestige of the empire just as did later the clergy to their Roman Church and its mysterious Latin writings. Based on four bodily "humors" that should be kept in balance, the Galenic system relied on bleeding and purges of the other bodily fluids according to which unbalanced humor they were thought to represent. To achieve these purges, a complete reference of herbs and concoctions was cataloged, all according to humoral affiliation.

The age of Galen was, for practicing physicians, a long period of dogma with no major progress, and then some rumblings around 1600 AD, with the influence of Galileo sparking interest in true scientific inquiry rather than orthodoxy. This reign of orthodoxy was roughly in parallel with that of the Roman church. What did change was the role of the chemist. In the Arab world, where many eastern herbs and minerals came to market, the role of the pharmacist was introduced (Porter 102) and trade with the west caused the apothecary to appear in Florence after 1200 AD (116). Sir William Osler said "The desire to take medicine is perhaps the greatest feature which distinguishes man from animals.(Dossey 164)" and a desire is surely bound to be met with a trade, perhaps the second ‘greatest feature.’ As society became more complex, this was a trade that took its place among the shops that lined the streets of any town, especially if it was a port.The first pharmacies opened their doors in Baghdad around 800 AD. Their trade soon included export to Europe and along with their wares, many of the writings of Arab physicians as well as Hippocrates and Galen (though it was held in reverence, only parts of his work had been preserved the West) made their way into western Europe by way of the Arab trade routes. An Arab named Ibn Said became known in Europe as Avicenna, the author of a system that revised Galen’s into an even more elaborate and self-assured arsenal of humoral indications and cures (Griggs 26). Galen had defined and stressed the idea of the "simple" – a plant possessing a single humoral quality. However, by around 1200 AD, the European practitioners of the new apothecary trade came to value complexity instead;

This tendency had already been fostered by the Arabs’ fondness for alchemy and for hiding unpleasant simples in sweet syrupy potions. So just as physicians developed an elaborate course of university study with its Latin materia medica to prop up their professional status and deride the common folk-healer, the druggist had exotic and mysterious potions to offer as the alternative to the boiled weeds of the herbalist. Galen too had offered some extravagant potions in his formulary, including a mixture called "Galene," his version of a traditional mixture called Theriac, whose ingredients were derived from extracts of animal, plant and stone found in all points of the known world; once assembled,

Arabian Alchemists made another major contribution to the orthodoxy of the age of Galen, a potion that would have alarmed Galen himself. The mining of poisonous Mercury had been stopped in Rome due to severe environmental pollution - as in 1988 the U.S. EPA declared scrap from dental fillings a hazardous waste (Carter 62) - but quicksilver was a central fixation of the alchemist’s art. By experiment, Arab physicians found that Mercury could be used as a topical treatment for all sorts of wounds and skin infections. This type of remedy found its way to the West, where the poisonous side effects were noted, but surgeons found it useful even so. Then, immediately after Columbus’ return from the New world, when the syphilis epidemic took hold, it was discovered that treating the sores with mercury also cleared up other symptoms – no matter about the poisoning. Perhaps there is some ironic justice in this invasion of syphilis from the New World and its attendant mercury poisoning upon the people of Europe. The Spaniards who first visited America brought plagues that wiped out entire tribes (including some of the "mound-builders," formerly thought to be ancestors rather than neighbors of the Colombus-Cortez era tribes) who had never seen a white man (Diamond 211-212).

Thus the two pillars of the Western "heroic" school of therapeutics were in place; purging, especially of blood, and mercury. Syphilis was such a shaming and insidious (it could be passed to children in birth) disease that people would endure the poisonous cures and this trade-off became accepted as a part of the physician’s way of doing business. While this bargain was not universally embraced, it came to be the majority approach to the cure of disease in Europe and its colonies up until the Industrial Revolution. Paris had been a pocket of resistance to chemical drugs, though the palace physician was a big fan of bloodletting. Another victory for the heroic school came in 1658 when Louis XIV was deathly ill with typhoid near the battlefront - antimony was finally administered (after much bleeding by his regular physicians) and his symptoms abated (Griggs 87). The only advances made were in the minds of the physicians as they associated themselves with learning and the Enlightenment; as Robert Buckman put it when describing the effect of Newton’s (an alchemist), Galileo’s and Descartes’ advances on the perception of medicine in Magic Or Medicine?, "The physicians themselves were increasing their social status and simultaneously increasing the amount of damage they could do with their treatments" (21).

One factor that allowed the quality of medicine to remain at such a pathetic level was public’s low expectations due to the rarity of health in Europe from the middle ages through the Reformation. It was a time of plague, pollution and poison. As the New World was explored, the robust good health of the Amerindians made an impression on the visitors. This difference in health of populations was marked enough to prompt the civilized folk, with their "cure-for-everything" mindset, to assume there must be a secret to the natives’ health and the tobacco leaf used in their smoke pipes became of fixation. A sad irony that fresh air, water and balanced diet were not even considered. In New Amsterdam, Dutch settlers noted in 1624 that

Let me add that at this point in history, hardly a European existed who had not taken mercury or antimony in some form – medicine was like a subtle plague, a disease of civilization that, along with the banishment of Hygeia by filthy city conditions, had settled on the Continent. Tobacco initially found its way to Europe as a medicine (Griggs 99) and so begins the story of how the fortune of colonial Virginia was made.

Galen’s influence was gradually giving way to some new theories, but few effective therapies resulted and the culture of medicine persisted as "the demise of Galean orthodoxy resulted in a reconstitution – this time using more scientific premises (Jones p14)." The standard "heroic" therapy was not the only risk to the sick; in the mid 1700s, historian John Bass estimated that more deaths resulted from Brunonianism than from The French Revolution or the Napoleonic wars combined (Skrabaneck 41). This was the therapy devised by John Brown based on sthenia or asthenia, requiring massive doses of opium or alcohol to equalize whichever was your particular "thenia". George Washington was killed by heroic treatments that added enough mercury and antimony to his system that today would merit a call to "911" and removed four pints of his blood (today we are only allowed to donate a single pint) for what was probably tonsillitis or a flu. And the advent of retail pharmacy was putting ever more mysterious substances into circulation – literally in the bloodstream of the people – market pressure was on a physician to prescribe a cure for any complaint; the medical historian Roy Porter points out in The Greatest Benefit to Mankind that "after 1750…healing was growing increasingly medication-centered. Prescription of medicines was the expected outcome of medical consultations…" (268). Such a codependent (Schaef 18) relationship persists today, as Melvin Konner writes,

The heroic style dominated until around the end of Napoleon’s adventures. At this time, the new art of Homeopathy scored a coup by leaving many more survivors of typhus among Napoleon’s troops than did the regular heroic treatments (Kaptchuk 82). And so a crisis brewed in the relationship between society and its physicians. Who were the true healers – the wise-women who many still turned to in the countryside, the heroic "regulars", one of the many sects of "irregulars"? At the same time, methods for manufacturing and marketing of both goods and ideas were becoming more powerful. The golden age of quackery was at its dawn.

Although "quack" has the slapstick connotation provided by the sound of Donald or Daffy Duck (or maybe "Duck Soup") to anybody born in the 20^th century, it is actually a shortened form of quacksalver, an insult used initially against heretical healers like the Swiss alchemist/physician Paracelsus, who was associated with the use of mercury in Europe ("Quacksalver"). The German form of the word is quacksalber (Carter 2, "Quacksalber"), apparently based on the word for quicksilver, quecksilber ("Quecksilber"). It came to be applied to anyone who practiced unorthodox medicine unless of course, they later proved to be a pioneer. In that case, the word did not appear in writings after the rehabilitation. I find much irony in this etiology since a quack of the original generation, practicing in 1550 was the prototypical chemotherapist, an ancestor of the heroic tradition. The contemporary heirs to this name targeted by the American Medical Association’s Committee on Quackery are often the opposite; modern-day nihilists who regard most pharmaceuticals and surgery as assaults on the patient.

When the 19^th century was well underway, nearly any physician could be considered a quack to somebody else. Physicians in Britain, for instance were aligned into many different associations by specialty and region. Most of the doctors were "regulars," who were graduated from the conventional schools and followed traditions more or less heir to Galen, with the addition of the "heroic" trend and some adjustments in tribute to scientific theory. There was little consensus and the bad reputation of the trade made way for competitions and alternatives.

One type of competition was the apothecary, formerly acting as primarily a wholesale supplier to doctors. Druggists in England found that they could open their doors directly to the public, give advice and even make house calls, increasing their ranks with a ratio of 1 druggist to every 20 physicians in 1780 to an equal number by 1840 (Loudon 231). In America, a popular resentment of physicians (exemplified by Benjamin Rush, the last great "heroic") swept the country along with the election of Andrew Jackson. Frustration with regular doctors opened the flood gates to a plague of medical commerce and evangelism. William Swaim, a bookbinder who started a business selling his formula "Panacea," managed to secure, in 1823, a written endorsement from Dr. Nathaniel Chapman, who was about to become the first president of the American Medical Association. He was a talented promoter who got similar support from many respected doctors and counted the Philadelphia Hospital as one of his best accounts. The formula was mostly sarsaparilla syrup, which was already included in the Pharmacopoeia of the Unites States, published at the same time that he went into business. Sarsaparilla was available as a French import, so his product was marketed to doctors as a bargain. He then exaggerated its applicability after getting doctor endorsements for certain limited uses. His example seems a prescription for the strategy of the drug trade in general in its rise to the most profitable industry on Earth.

Though doctors could not yet cure many diseases, they were learning much more about how to diagnose those diseases. And in the mid-1800s, great strides were being made in the isolation of various agents like cocaine, morphine and quinine from their raw plant form (Porter 334). At least doctors could manage their patients’ pain in a more scientific style, allowing them to distance themselves further from "folk" healers – though these were without exception extracts from traditional medicinal plants. Germany became the world center of medical research and training, with a research rather than clinical emphasis, drawing students from all over; America for example, had 15,000 medical students in the country at the beginning of the Great War (335). By the end of the 19^th century, Germany was also the capital of pharmacy and drug manufacture (Flannery 161), and has remained near the head of the pack even through its wartime disasters in this century.

Calomel (mercury chloride), one of the industry’s biggest moneymakers, was certainly spread by the physicians, but somebody had to supply the stuff. It is now thought by many that the general mercury poisoning of the western world during the 19^th century was a factor in the spread of tuberculosis, and women, who were more often consumptive, were more frequently dosed than men, because mercury was pushed as a remedy for both menstrual and pregnancy problems (Griggs 237). This is perhaps an unmined lode for research into the subjugation of women in that time – the consumptive and the hysteric woman were popular archetypes in the Romantic and Pre-Raphaelite esthetic (Dubos 201). Mercury was freely prescribed as a purgative, often to counter the constipation caused by laudanum. This was standard "physic," the way of the "regulars" - even more damage may have been caused by the nostrum vendors. Though the "Q-word" was applied to individual practitioners, the most dangerous players in the healing game were the vendors of drugs. Powerful substances had always been available from the apothecary, but now the mass production techniques that were being applied to both the potions and their packaging and marketing could spread a poison with great efficiency. Large pharmaceutical firms had sophisticated sales corps, deploying "detail men" to the offices of doctors, hospitals and druggists with samples and promotional information. I have not yet determined where or when the role of the "detail man" originated, but it is mentioned as a matter of course, from the Victorian age and increasingly into the 20^th century, in every book concerning American medical and pharmacy history I have read or scanned. The American Heritage dictionary defines "detail man" without attribution or first appearance.

The "Patent Medicine" vendors got their name from the fact that they had patents on their medicines; however the patents were on the shape of the bottle, the box and the label art. They found the need to band together under a name after the more established drug houses began to try to differentiate themselves from nostrum-makers by dubbing their products "Ethical Medicines." The patents secured were to assure that their esteemed customers could identify exactly which nostrum they were buying without getting an inferior imitation nostrum in the same color bottle. Most Patent Medicines were "tonics" - alcohol with a few other substances added, such as opium, morphine or codeine, along with some distinctive flavoring and coloring agents. In light of the heroic remedies, it may be that many of the nostrums only created narcotics addicts, which was probably not as bad as mercury poisoning. The Patent vendors were in a cut-throat market and it must have been very profitable. The modern age of advertising began here. In James Young’s Toadstool Millionaires, an English visitor’s astonished remarks about the ubiquity of outdoor nostrum advertising indicates a level of avarice that is very modern. Barns and bridges were covered with ads, as well as signs erected along railroad lines – these are all too familiar – but the advertisers knew no limits – signs were painted along Niagara Falls, on the Palisades of the Hudson River, in Yellowstone Park on the cliffs. Vendors attempted to buy space on the base of the Statue of Liberty and on Mount Ararat (123). And the money gave a boost the advertising industry; Young quotes an ad-man of that time:

At the end of the 19^th century, the public was aware that Pasteur and Koch had made scientific discoveries about disease that involves things called "germs." They were no savvier about the details of those discoveries than a typical TV-watcher of today’s "information age" would be about gene therapy or cloning. This allowed the likes of William Radam, the vendor of the "Microbe Killer" nostrum to claim that "A microbe is a microbe" and that all disease was simply "decay" – he published a book featuring photographs of various microorganisms claimed to be the first publicly available (Young 157).

Men like Swaim, Hopkins and Radam had a good long run at the public’s money and they created a culture that did not go away, even in 1906, when T. Roosevelt signed the Pure Food and Drugs Act, requiring disclosure of ingredients on labels (Young 244). Tonics were still popular, sans opium, in the 1930’s, when Lewis Thomas was a medical student:

Most advances in health, including major improvements since Victoria are due to improved hygienic knowledge and practice, not medicine. While the study of biology, human anatomy and physiology had made some advances, no applications had been made to the cure of human illness (Dubos 134, Thomas, Fragile 11). The improvements in public hygiene only came about in reaction to the horrors of tenement life observed in the mid-nineteenth century. The Great Sanitary Movement in Europe and similar trends in America had their effect before anyone (including Florence Nightingale) yet believed in germs; what they saw was filth and squalor and improving conditions in towns and hospitals had a strong effect against disease. The association of this trend with scientific medicine is a statistical mistake that is not pointed out by most medical educators (Dubos 126, Konner 82).

The trend in conventional medicine was typified by Oliver Wendell Holmes, who proposed that dumping the entire pharmaceutical stock of civilization into the ocean would be "all the better for mankind – and all the worse for the fishes." This trend was labeled medical "nihilism" as opposed to "heroism," which still enjoyed some favor. Unfortunately for us all, the new therapeutic conservatism on the part of the doctors simply left a vacuum in the supply for treatments that the public was still hooked on, in many cases physically, since laudanum and morphine products were household staples. The patent medicine sellers learned to adopt the look and style of the "ethical medicine" products. They began to sponsor medical journals and used their own detail men (Young 159). So in the end the the 19^th century, there was no rigid definition of what a doctor or a druggist was. The "regulars" had pulled into a group and formed the American Medical Association in 1847; they were a majority, but with no center. There were also Eclectics and Homeopaths, plus many smaller sects of medical practice, often taking potshots at each other, sometimes subscribing to multiple theories and occasionally changing sides, like George Simmons, the former homeopath who became editor of AMA’s Journal in 1899.

To practice as a physician required little preparation; there were few laws or licenses and to secure the title of M.D. was not hard if you could pay for the school. By 1876, there were 62 "proprietary" trade schools of regular medicine as well as 11 for homeopaths and 4 for eclectics (Porter 530). The few university programs were of the "regular" stripe. The AMA was searching for ways to gather its strength and prestige. On the strength side, the Journal began accepting advertising from the Patent Medicine companies in 1905, which did not help on the prestige front (Griigs 248). There was also too much competition from "irregulars," who tended to be poor customers for their advertisers as well. One tactic that had gained some ground was amnesty; in 1901, the AMA simply invited sectarians to join the fold. Shoring up the prestige front, which was still taking many a flaming arrow, a Council on Medical Education was formed in 1902, and in 1907, began visiting some of the 160 schools then in business (249). They were, however, not up this task (partly because colleges were among their main constituents) and were lucky enough to be rescued by the Carnegie Endowment for the Advancement of Teaching, who were smooth indeed, drawing up an agreement with the AMA’s Council that

Carnegie’s man was Abraham Flexner, an educator rather than a doctor, who instead of attempting to inspect a school’s laboratories and curriculum, followed a set of standards likely prepared by the AMA and "after one-half hour of studying student credentials, he could tell whether the standards were being upheld. In a matter of hours, he could determine whether or not the school was worthy of money" (Achterberg 175). He visited 155 schools and by 1914, four years after The Flexner Report was published, there were only 100 (175). Flexner was enamored of the German model, with emphasis on lab rather than clinic, on big university towns and of course, on pharmacology; Johns Hopkins was the only school to get full approval (Porter 530). After the wrath of his report had dealt the death cut to the most fraudulent of the schools, Flexner was hired on by Rockefeller, whose General Education Board then set about doling out grants to the most compliant schools, who would then join the Association of American Medical Colleges, in exchange for seats on boards of directors. So with the assistance of both Carnegie and Rockefeller, the AMA took the helm of American medicine.

For the successful doctors of that time, another boon was that this winnowing down of schools reduced the ranks of doctors and increased demand. Another event gave the American pharmaceutical companies a major boost; in 1917, the Trading with the Enemy Act allowed German drug patents to be handed over to US firms under government license (Griggs 262). Since there was no research cost, the profits were immediate and the interest in further profits caused major investment, which of course included investments in advertising in the Journal of the AMA and in contributions to the new breed of medical schools.

Since this series of events, there have been many advances in scientific medicine, but the basic structure of the relationship between American physicians and the pharmaceutical industry has continued. The AMA still gets 20% of its revenues from Pharmaceutical advertising (Wolinsky xii) and the preferred method of healing is determined by profit potential. There are now many other players vying for these potential profits, including insurance companies and many providers of specialized products and services. The very professionalization of human service industries is a money-maker for the professional class and a creator of dependency for the people who become "clients" of those services – essentially everyone, according to critics like Ivan Illich and John McKnight, who writes "Like a hall of mirrors, the problem definer creates the treatment that creates the problem and creates the remedy…" (21)

This also alludes to the fact that an unhealthy relationship has developed between the sick and their healers. In the period in the beginning of this century, before many of the cures we now expect were developed and while the consolidation of the power of the AMA and the Pharmaceutical Manufacturer’s Association was taking place, doctors were doing a pretty good job of being doctors. The image of the doctor gained great prestige and probably reached its peak in the 1960’s. But then the way we work with our doctors began to change. "Fewer patients were lost to disease, so counseling was less in demand. The need for an effective bedside manner was replaced by the need to learn prescriptions" (Buckman 115). This approach also industrialized scheduling so that doctors began to spend less time with patients. The generation of trained General Practitioners began to die out and the portion who were specialists increased. Doctors became businessmen, partly motivated by their huge tuition loans. More testing equipment and preemptive medicines came into play as people began suing their doctors. How many people, especially parents of schoolchildren, have never secured a "phone-in" prescription for some malady? The doctor becomes essentially an approving authority; if the caller’s story is convincing, drugs are dispensed. Sometimes, the message is relayed to the doctor by office staff, and the patient and doctor never even speak to each other.

A feeding frenzy of healthcare products and services has helped Americans to spend 14% of the gross domestic product on health care, more than any other country, currently in the neighborhood of 1 trillion dollars. This high figure is not based on high medical needs, and this effect of consumption based on marketing rather than need is not restricted to America. A 1988 survey of European prescription patterns tabulated the most prescribed drugs by country, and here are the top sellers:

England: Ventolin, an English drug.

Germany: Erglukol, a German drug.

France: Tanacort, a French drug.

Italy: Tagamet, an Italian drug.

Belgium: Fibromycin, a Flemish drug. (Carter 231)

And on the hidden side of this equation, there are the drug makers, who furiously compete for their share of the doctor’s attention when he dutifully writes out his prescription. Because the American drug business is more powerful than its regulators, most of the information about drugs comes from their vendors, and the FDA is prevented from advising doctors on how they compare, as Stephen Fried, a journalist, was astonished to learn:

In healing, there is always an element of faith involved – no matter if the transaction takes place in the jungles of Brazil or in the Sloan Kettering medical center. The patient has faith in the doctor or the medical system, the doctor has faith in the technologies and drugs. Faith is invested in the parts of the system which are least understood and the least understood, aside from the human immune system itself, is the effects of drugs. A recent article in Discover magazine exemplifies the misplaced faith in progress that is endemic to this situation, it is the cover story, "Drugs From the Sea," with a picture of a medicine bottle containing an undersea scene of tropical fishes and coral. The label on the bottle reads like the devotional creed for consumption of the customers of the pharmaceutical business:

This article of four pages is placed immediately following a 28 page advertising section placed by the American Academy of Allergy, Asthma and Immunology (AAAAI), labeled as a "Sponsored Educational Supplement" and consisting of 12 pages of drug ads interspersed with 4 pages of information about the Association’s member companies and least of all a few pages on the subject of allergies – focused on managing allergies with drugs.

The U.S. medical establishment uses powerful influences to sell a very profitable myth of "health care" to a public that during modern times has placed faith in them much as aboriginal people trusted their medicine men. This social role has been split apart and delegated into specialties for industrial efficiency. But the role, once sacred, has become debased because the ability of a healer to care for individuals as fellow human beings has been disrupted. The medicine manufacturers in particular have worked very hard to manage public perception of their very profitable enterprise so that it appears that they are part of a united front, providing a vital service to humankind. The fundamental human need for help in healing is unmet by most of our "health care system" – among both doctors and patients there is unrest and confusion. HMOs are hosting New Age health seminars and paying claims for Complementary therapies – the trend is a little like that in the time of Andrew Jackson. The medical schools and even the AMA are bending with this trend to attempt to train doctors in a more humane way (Deci 175, Konner 233). And since the 1980’s there has been an effort to encourage more graduates to choose general ("family") practice. Instead of producing more GPs, we are instead importing people from poorer countries like Abraham Verghese, who has told his story in books and articles like The Cowpath to America. Let us hope that in the opportunity of this chaos, the balance can be found among our relations with the family of Asklepios; a bit less reliance on Panacea and a closer relationship with Hygeia, her kinder and less flamboyant sister.