Journal of the Royal Society of Medicine Volume 85 January 1992
are occasionally observed. Similarly, ipratropium bromide confers bronchodilatation at a dose approximately one-tenth of that required to inhibit the production of saliva, and one-fifth ofthe dose required to cause tachycardia. High dose inhaled corticosteroids may cause suppression of the hypothalamic-pituitaryadrenal axis, alteration of insulin and lipid metabolism, increased bone resorption and cutaneous changes. The incidence of these systemic effects, however, is much lower than when oral corticosteroids are used'2. In addition to their advantages, several disadvantages or problems have also been proposed for drugs administered as aerosols, but these seem to be of minor importance. Fears that the aerosols will not reach the lung periphery in sufficient quantity in the presence of airway obstruction or mucus hypersecretion are usually unfounded, despite the reduced aerosol penetration that may occur under these circumstances. Tolerance to the acute effects of inhaled j3-agonists does not develop in asthmatic subjects for the dose levels of drug normally used. There has been considerable concern about safety of inhaled 0agonists, particularly following the increase in deaths from asthma in England and Wales in the 1960s, which showed a statistical correlation with the sales of pressurized isoprenaline aerosols. It is now thought that this epidemic resulted from failure to implement more powerful forms of treatment in severe asthma rather than from a direct toxic effect of the MDIs themselves. The proposed disadvantages of aerosol therapy mentioned above do not seem to be of major importance, and are greatly outweighed by the advantages that this route of delivery offers. However, it is important to remember that it is much more difficult to inhale an aerosol than to take a pill. Physicians must make sure that patients prescribed inhalation therapy receive adequate tuition. Patients should also know the circumstances under which they should take the various types of drug and that they should seek further medical advice if their treatment becomes less effective. At the same time,
The portrayal of the physician in nonmedical literature - the physician and his fee General introduction Physicians are described in works of fiction in enormous numbers. In the older literature they occasionally turn up as poisoners1 and outlandish fools2 or with behaviour patterns suited to practitioners bearing names like Slop3, Nockemorf4, Fillgrave5, Cuticle6 and Patella6. Sometimes, as in Wycherley's 'The Country Wife'7 or in Dickens' 'Martin Chuzzlewit'8, physicians, while not committing any illegal acts, engage in activities nowadays considered incompatible with mainstream medicine. Anonymous physicians appear in large numbers 'healing', 'searching wounds' and 'giving good salves'9. In modern works of fiction they diagnose
5
the manufacturers of nebulizers, MDIs and dry powder inhalers must ensure that these devices do in fact produce an aerosol within the respirable range.
G Di Benedetto S W Clarke Department of Thoracic Medicine Royal Free Hospital, Pond Street London NW3 2QG
References 1 Swift DL. Generation and respiratory deposition of therapeutic aerosol. Am Rev Respir Dis 1980;122:71-7 2 Newman SP, Pavia D, Garland N, Clarke SW. Effects of various inhalation modes on the deposition of radioactive pressurised aerosols. Eur J Respir Dis 1982;63(suppl 119):57-65 3 Newman SP, Clarke SW. The proper use of metered dose inhalers. Chest 1984;86:342-4 4 Konig P. Spacer devices used with metered dose inhalers. Breakthrough or gimmick? Chest 1985; 88:276-84 5 Toogood JH, Baskerville J, Jennings B, Lefcoe NM, Johansson S-A. Use of spacers to facilitate inhaled corticosteroid treatment in asthma. Am Rev Respir Dis 1984;129:723-9 6 Molina MJ, Rowland FS. Stratospheric sink for chlorofluoromethanes: chlorine atomcatalysed destruction of ozone. Nature 1974;249:1810-12 7 Pedersen S. How to use a Rotahaler. Arch Dis Child 1986;61:11-14 8 Jones K. New delivery systems for asthma drugs. Practitioner 1989;233:265-7 9 Newman SP, Pellow PGD, Clarke SW. Droplet size distributions of nebulised aerosols for inhalation therapy. Clin Phys Physiol Meas 1986;7:139-46 10 Steventon DR, Wilson RSE. Facemask or mouthpiece for delivery of nebulised bronchodilator aerosols. Br J Dis Chest 1981;75:88-90 11 British Thoracic Society, Research Unit of the Royal College of Physicians of London, King's Fund Centre, National Asthma Campaign. Guidelines for the management of asthma in adults. I. Chronic persistent asthma. BMJ 1990;301:651-3 12 Stead RJ, Cooke NJ. Adverse effects of inhaled corticosteroids. BMJ 1989;298:402-3
pregnancy, they give pregnant women an expected date of confinement or they pronounce life extinct. 'A red-headed intern filled out a DOA form and clipped his stylus to the outside pocket of his white jacket' 0o. In some fictional physicians the medical degree is relevant only as a plot device. Dr Jekyll, who was a medical practitioner during the day and a monster at night, might as well have had stockbroking as his regular occupation"l. Doctor Watson, the unteachable disciple of Sherlock Holmes12 had a medical degree but could have played the confidant's role almost as well had he been a theology student. Doctor Aziz, the principal character in Forster's 'Passage to India'13 who is falsely accused of attempted rape, neither thinks nor behaves like a medical doctor. Even if these anonymous physicians and pseudophysicians are ignored, there still remain many fictional descriptions of medical doctors and their activities. There is at least one anthology of medical
0141-0768/92/ 010005-03/$02.00/0 i 1992 The RoyM Society of Medicine
6
Journal of the Royal Society of Medicine Volume 85 January 1992
passages from the non-medical literaturel4 and there is a relatively recent paper discussing medical heroes in 19th century British fiction'5. In this series of papers an attempt is made to find some underlying themes in the portrayal of physicians by predominantly non-medical writers. How do such writers perceive the physicians' attitudes to religion, to money, or to their colleagues? What do they say about a physician's behaviour during a confrontation with an angry patient? How does the fictional physician relate to his wife and to other members of his family? Why is it that although women have been practising medicine for over 100 years, the conflict between women's traditional activities and a medical career appears unresolved? Obviously, non-medical fiction does not provide definite answers to these questions but recognizable patterns emerge. The passages selected are illustrative rather than comprehensive. They are not necessarily taken from literary masterpieces (though many of them are) nor do they necessarily represent historical 'firsts' (though many of them do). No attempt has been made to perform statistical analyses. The physician and his fee 'Physicians of the utmost fame Were called at once but when they came They answered as they took their fees "There is no cure for this disease"."96 Stories about physicians' payments are as old as stories about physicians themselves. Pindar's account of Asclepios'7 which dates from the 5th century BC describes the mythical father-figure of medicine who knew when to reassure his patients, when to give medical treatment and when to us the knife. Unfortunately, he was corrupted by 'a splendid fee of gold' and punished appropriately. Geoffrey Chaucer's physician, who had 'a particular love for gold', had made a fortune during the plague years and was engaged in profit-sharing arrangements with an apothecary'8. The Doctor of Physic in Shakespeare's Macbeth'9, is portrayed with a great deal of sympathy. He takes a medical history, he comments on particular physical signs and he has sufficient humility to declare 'this disease is beyond my practice'. He is discreet, observant and compassionate. Yet even this man is made to discuss his profit before he leaves the stage19. Turgenev's 'District Doctor' 'deftly slid a five rouble note up his sleeve coughing dryly and looking away as he did so'20. In a somewhat blacker humour Proust2l describes a similar event during a theatrical scene enacted around a death-bed. Dr Dieulafoy, a consultant physician, whose main function in life consists of certifying that a particular patient is in extremis, has been summoned. 'In the majesty of his frock coat the Professor would enter the room, melancholy without affectation, uttering not a word of condolence that could have been construed as insincere ... Having examined my grandmother. .-. he murmured a few words to my father ... bowed respectfully to my mother and made a perfect exit, simply accepting the sealed envelope that was slipped into his hand. He did not appear to have seen it ... with such a conjurer's dexterity had he made it vanish.'21 Doctk# Faustus22 by Thomas Matn contains a fearful scene where the agony of a child dying of meningitis is described in pitiless detail. The local
practitioner who is unable to cope has asked for a consultation with a physician from the capital. 'The next afternoon the consulting authority arrived from Munich. He was a tall man ... with a social presence ... much sought after and high priced.'22 Leo Tolstoy, who was deeply suspicious of medical science had a strong dislike for medical doctors and a pathological obsession with the 'indecency' of the physical examination. Pozdnychev in The Kreutzer Sonata23, who tells a chance acquaintance on a train how he had murdered his wife, complains bitterly about 'doctors who cynically undressed her and felt her all over - for which I had to thank them and pay them money ... I understand they want to earn money like lawyers and others' but somehow this character (and Tolstoy) seem to resent physicians' fees to a greater extent than those ofother professionals. Dr Daneeka in 'Catch 22', like Chaucer's physician, has a kickback fee arrangement with drug stores2A. Unlike the other characters in the book who worry about staying alive or engage in personal squabbles with fellow members of the military establishment, Doc Daneeka spends most of the war brooding about his loss of income. 'I don't want to make sacrifices, I want to make dough'25. Despite the great diversity of these passages a common theme runs through them all. Pindar and Proust, Geoffrey Chaucer and Joseph Heller (not to mention contemporary journalists) all appear obsessed with the doctor's payment, his wealth and his greed. This sentiment is so deeply entrenched that there are even suggestions that the atypical physician who is not interested in money can not be any good at his job. 'A physician who heals for nothing is worth
nothing'26. *
Dostoyevsky deliberately contrasts two medical practitioners. The local physician was a 'kind-hearted, humane man who treated his poor patients .. for nothing, went into their hovels . . . left money for medicine'27 but his visits 'were of little avail'28. On the other hand, the famous Moecow specialist who was obviously contemptuous of the Snegiryovs and their poverty and who bellowed in 'a loud peremptory voice' had come over 'for a large fee' 29. Lawrence Sanders30 tells of an encounter between Captain Edward X Delaney, a senior New York police officer and a Dr Spencer who informs him that his wife will have to have an operation on her kidney. 'Do you anticipate any trouble, doctor?' he asked. The surgeon ... looked at him coldly. 'No' he said. (Dr Spencer subsequently performed a nephrectomy and Mrs Delaney died as a result of a Proteus infection). 'I tut him' Delaney said . . . 'He's a professional. I asked Ferguson to check him out and he said Spencer is a fine surgeon and a wealthy man'. 'Good' Barbara smiled faintly, 'I wouldn't want a poor surgeon' 3. *This statement which is often quoted out of context comes from a passage describing how a successful plaintiff in an assault case may foil a dfdendant's attempts to minimize his medical costs. Ifthe defendant (presumably a physician who injured the plaintiff in the first instance) offers to treat him himself, the plaintiff is entitled to reject this 'generosity'. If the defendant tries to introduce the injured individual to a physician who will treat him free of charge the plaintiff may counter by saying a physician who charges no fee is worth none. If the defendant proposes to bring a physician from out of town the plaintiff has the right to refuse this offer alsof.
Journal of the Royal Society of Medicine Volume 85 January 1992
This brings up the question of why the physician's 7 Wycherley W. The Country Wife (1675). In: Friedman A, ed. The Plays of William Wycherley. Oxford: Clarendon fee should be resented and commented on any more Pij 1979;24&44 disparagingly than that of the builder or the 8 Dickens C. The Life and Adventures ofMartin Chuzzlewit dressmaker. Why should an appropriate remuneration (1844). London: Oxford University -Pres 1959:437 be considered incongruous in a doctor? Fiction writers 9 Malory T. Le Morte D'Arthur (1485). London: Dent, do not address this problem specifically but here 1938:40-2 and there one can find hints. The priest-like figure 10 Chandler R. The Little Sister (1949). In: The Chandler with his ritual, his vestments and his specialized Collection, vol. 1. London: Picador, 1983:424 vocabulary, with his ability to examine body and sQul 11 Stevqn- RL. The Strange Case of Dr Jekyll and suddenly becomes a common tradesman when he Mr' Hyde (1886). London:'Heinemann, 1924 demands a fee. 'We are angels when we come to mire, 12 Knox R. Studies im the Literature of Sherlock Holines. In: Haining P, ed. A Sherlock Holmes Compendium, devils when we ask for payment'31. London: W. H. Allen, 1980:47-65 Demanding a fee might-be appropriate behaviour 13 Forster EM. Passage to India (1924). London: Penguin, for a barber surgeon (a once-off fixer), a dentist or an 1988 apothecary. It might even be appropriate for a 14 Cousins N, ed. The Physician in Literature. Philadelphia: 19th century medical practitioner who supplied his 1982 Saunders, patients with 'pink and browu mixtures'32 and Who 15 Hill J. The doctor as hero in nineteenth century British provided 'somethingmeasurable' for which he could. fitioti, The- Pharos of Alpha Omega- Alpha 1987:50; submit an itemized account32. It; is evidently. con, 31-33 sidered inappropriate for -the physicianl. who tis 16 Belloc H. Cautionary Verses. Edinburgh: Duckwortb/ perceived to function as a hybrid betwee. aGoa Nelse, 1940:18-19Samaritan and a Faustiai -seeker- of knowledge -j 17Z Pindar, Pythian Odes (approx. 474 BC). In: San"dys J, trans. The Odes of Pindar. London: Loeb Classical The problem is discussed in considerable4detailby Ibray, Heinema, 19$i8:189-91 Anthony Trollope. Doctor Thorne33Sb aroused the 18 Chaucer G. Canterbury Tales (approx. 1390) In: Fisher displeasure of his 'Barchester' colleagues by charging JH, ed. The Complete Poetry and Prose of Geoffrey somewhat less than the coxou.fee aMl; by actuallyCh&$er.- ew York: H1lt, iThineiart and''Winston, fishing around in his trousdrpcketfurthe uWcessary 1927':17-1A t,, change after a consiltatien.-'A physician should take 19' Shakespeare W. In: Wright LB, la'MarVA, s. The his fee without letting his left hand know -what his, -lage& of Macbeth (1606), Adt V, Scenes I AnlIl. New right hand was doing. It should be taken without a York: Wahington Squrare Presh, 1969077-84 thought, without a look, without a move of the facial 20 Turgenev I. The Diatrict D)octr (1852). In: Garnett C, tra8sl. The Novels of Ivan Turgenev,- vol. 1. London: muscles. The true physician should hardly be aware -Hei!nem n, 1920:56 that the last friendly grasp of-the hand had been made 21 Proust M0. In: Scott-Moncrieff CK, Kilmartin T, more precious by the touch of-gold'33 transl. Remembrance of Things Past (1913-1922). Somehow we are all onscious of these.sentiments HarmondsWorth: Penguin, 1987:Vol 2;354-5 and the medical profssio emhploys tens of thousands 22 Mann T. In: Lowe-Porter' HT, transl. Doctor Faustus of receptionists whose main function is to separate the 1947. 1ondon: Secker-and Warburg, 1949-475-6 'handshake' from the 'gold'. 23- Torsty L. The Kreutzer Sonata (1891). In: Maude A, rtranol. Leo Tolstoy, Short Novels vol 2. New !York: SolomPn Posen Medern Library odooe, 1966:148-9-Nor,th $here MVedicul ,Centre - 24 ReAer. J. Catch 22 (1962). New York: DelL Publishing 66 Pacific, Highway, S Leonmrds 2065, q,,974:41 Australia 25 Ibi, p 33. 26 Kirner EW, transl. Epstein I, ed. Babylonian Talmud, References Baboc Kamma (approx.'450 AD) London: Soncino Press, 1 Jonson B. Sejanus His Fall (1604). In: Herford OH, 1964:85a Simpson P, eds. Ben Jonson, vol. 4. Oxford: Clarendon 27 Dostoyevsky F. In: Magarshak D, transl. The Brothers Press, 1966:379 Krazov (1880).- Hairmondswoth, UK: 1978:Vol 2; _
2 Behn A. Sir Patient .ancy (1678). In: Summers M, ed. The Works of Aphra &hn, vol. 4. New York: Pha6toni Press, 1967:98-107D 3 Sterne L. The Life and Opinions of Tristram-Shandy)
Gentleman (1759-176-) London:, Dest,
1924:76
4 Dickens C. Pickwick Papers.(1837). New York: Signet Classics, New American Library., 1964;726 5 Trollope A. Doctor Thorne (1858). London: Oxford
University Press, 1963:123 6 Melville H. White Jacket (1850). New- York: Grove Press, 1959:238
790 28 TIbid;p 633 29 Ibidp-B48; 30 Sanders L.; The Fir*Dwdly Sin. London: W, H Allen,
*1974;87 Scott W; The Abbot (1831). London: Adam and Charles Black, 1893:280 32 liot G. Middlemarch (1871-2). London: Penguin Books, 1988:484-485 33 Tr6llope' A. Doctor Thorne (1858). London: Oxford UJniversity Press, 1963:123
31
7
are occasionally observed. Similarly, ipratropium bromide confers bronchodilatation at a dose approximately one-tenth of that required to inhibit the production of saliva, and one-fifth ofthe dose required to cause tachycardia. High dose inhaled corticosteroids may cause suppression of the hypothalamic-pituitaryadrenal axis, alteration of insulin and lipid metabolism, increased bone resorption and cutaneous changes. The incidence of these systemic effects, however, is much lower than when oral corticosteroids are used'2. In addition to their advantages, several disadvantages or problems have also been proposed for drugs administered as aerosols, but these seem to be of minor importance. Fears that the aerosols will not reach the lung periphery in sufficient quantity in the presence of airway obstruction or mucus hypersecretion are usually unfounded, despite the reduced aerosol penetration that may occur under these circumstances. Tolerance to the acute effects of inhaled j3-agonists does not develop in asthmatic subjects for the dose levels of drug normally used. There has been considerable concern about safety of inhaled 0agonists, particularly following the increase in deaths from asthma in England and Wales in the 1960s, which showed a statistical correlation with the sales of pressurized isoprenaline aerosols. It is now thought that this epidemic resulted from failure to implement more powerful forms of treatment in severe asthma rather than from a direct toxic effect of the MDIs themselves. The proposed disadvantages of aerosol therapy mentioned above do not seem to be of major importance, and are greatly outweighed by the advantages that this route of delivery offers. However, it is important to remember that it is much more difficult to inhale an aerosol than to take a pill. Physicians must make sure that patients prescribed inhalation therapy receive adequate tuition. Patients should also know the circumstances under which they should take the various types of drug and that they should seek further medical advice if their treatment becomes less effective. At the same time,
The portrayal of the physician in nonmedical literature - the physician and his fee General introduction Physicians are described in works of fiction in enormous numbers. In the older literature they occasionally turn up as poisoners1 and outlandish fools2 or with behaviour patterns suited to practitioners bearing names like Slop3, Nockemorf4, Fillgrave5, Cuticle6 and Patella6. Sometimes, as in Wycherley's 'The Country Wife'7 or in Dickens' 'Martin Chuzzlewit'8, physicians, while not committing any illegal acts, engage in activities nowadays considered incompatible with mainstream medicine. Anonymous physicians appear in large numbers 'healing', 'searching wounds' and 'giving good salves'9. In modern works of fiction they diagnose
5
the manufacturers of nebulizers, MDIs and dry powder inhalers must ensure that these devices do in fact produce an aerosol within the respirable range.
G Di Benedetto S W Clarke Department of Thoracic Medicine Royal Free Hospital, Pond Street London NW3 2QG
References 1 Swift DL. Generation and respiratory deposition of therapeutic aerosol. Am Rev Respir Dis 1980;122:71-7 2 Newman SP, Pavia D, Garland N, Clarke SW. Effects of various inhalation modes on the deposition of radioactive pressurised aerosols. Eur J Respir Dis 1982;63(suppl 119):57-65 3 Newman SP, Clarke SW. The proper use of metered dose inhalers. Chest 1984;86:342-4 4 Konig P. Spacer devices used with metered dose inhalers. Breakthrough or gimmick? Chest 1985; 88:276-84 5 Toogood JH, Baskerville J, Jennings B, Lefcoe NM, Johansson S-A. Use of spacers to facilitate inhaled corticosteroid treatment in asthma. Am Rev Respir Dis 1984;129:723-9 6 Molina MJ, Rowland FS. Stratospheric sink for chlorofluoromethanes: chlorine atomcatalysed destruction of ozone. Nature 1974;249:1810-12 7 Pedersen S. How to use a Rotahaler. Arch Dis Child 1986;61:11-14 8 Jones K. New delivery systems for asthma drugs. Practitioner 1989;233:265-7 9 Newman SP, Pellow PGD, Clarke SW. Droplet size distributions of nebulised aerosols for inhalation therapy. Clin Phys Physiol Meas 1986;7:139-46 10 Steventon DR, Wilson RSE. Facemask or mouthpiece for delivery of nebulised bronchodilator aerosols. Br J Dis Chest 1981;75:88-90 11 British Thoracic Society, Research Unit of the Royal College of Physicians of London, King's Fund Centre, National Asthma Campaign. Guidelines for the management of asthma in adults. I. Chronic persistent asthma. BMJ 1990;301:651-3 12 Stead RJ, Cooke NJ. Adverse effects of inhaled corticosteroids. BMJ 1989;298:402-3
pregnancy, they give pregnant women an expected date of confinement or they pronounce life extinct. 'A red-headed intern filled out a DOA form and clipped his stylus to the outside pocket of his white jacket' 0o. In some fictional physicians the medical degree is relevant only as a plot device. Dr Jekyll, who was a medical practitioner during the day and a monster at night, might as well have had stockbroking as his regular occupation"l. Doctor Watson, the unteachable disciple of Sherlock Holmes12 had a medical degree but could have played the confidant's role almost as well had he been a theology student. Doctor Aziz, the principal character in Forster's 'Passage to India'13 who is falsely accused of attempted rape, neither thinks nor behaves like a medical doctor. Even if these anonymous physicians and pseudophysicians are ignored, there still remain many fictional descriptions of medical doctors and their activities. There is at least one anthology of medical
0141-0768/92/ 010005-03/$02.00/0 i 1992 The RoyM Society of Medicine
6
Journal of the Royal Society of Medicine Volume 85 January 1992
passages from the non-medical literaturel4 and there is a relatively recent paper discussing medical heroes in 19th century British fiction'5. In this series of papers an attempt is made to find some underlying themes in the portrayal of physicians by predominantly non-medical writers. How do such writers perceive the physicians' attitudes to religion, to money, or to their colleagues? What do they say about a physician's behaviour during a confrontation with an angry patient? How does the fictional physician relate to his wife and to other members of his family? Why is it that although women have been practising medicine for over 100 years, the conflict between women's traditional activities and a medical career appears unresolved? Obviously, non-medical fiction does not provide definite answers to these questions but recognizable patterns emerge. The passages selected are illustrative rather than comprehensive. They are not necessarily taken from literary masterpieces (though many of them are) nor do they necessarily represent historical 'firsts' (though many of them do). No attempt has been made to perform statistical analyses. The physician and his fee 'Physicians of the utmost fame Were called at once but when they came They answered as they took their fees "There is no cure for this disease"."96 Stories about physicians' payments are as old as stories about physicians themselves. Pindar's account of Asclepios'7 which dates from the 5th century BC describes the mythical father-figure of medicine who knew when to reassure his patients, when to give medical treatment and when to us the knife. Unfortunately, he was corrupted by 'a splendid fee of gold' and punished appropriately. Geoffrey Chaucer's physician, who had 'a particular love for gold', had made a fortune during the plague years and was engaged in profit-sharing arrangements with an apothecary'8. The Doctor of Physic in Shakespeare's Macbeth'9, is portrayed with a great deal of sympathy. He takes a medical history, he comments on particular physical signs and he has sufficient humility to declare 'this disease is beyond my practice'. He is discreet, observant and compassionate. Yet even this man is made to discuss his profit before he leaves the stage19. Turgenev's 'District Doctor' 'deftly slid a five rouble note up his sleeve coughing dryly and looking away as he did so'20. In a somewhat blacker humour Proust2l describes a similar event during a theatrical scene enacted around a death-bed. Dr Dieulafoy, a consultant physician, whose main function in life consists of certifying that a particular patient is in extremis, has been summoned. 'In the majesty of his frock coat the Professor would enter the room, melancholy without affectation, uttering not a word of condolence that could have been construed as insincere ... Having examined my grandmother. .-. he murmured a few words to my father ... bowed respectfully to my mother and made a perfect exit, simply accepting the sealed envelope that was slipped into his hand. He did not appear to have seen it ... with such a conjurer's dexterity had he made it vanish.'21 Doctk# Faustus22 by Thomas Matn contains a fearful scene where the agony of a child dying of meningitis is described in pitiless detail. The local
practitioner who is unable to cope has asked for a consultation with a physician from the capital. 'The next afternoon the consulting authority arrived from Munich. He was a tall man ... with a social presence ... much sought after and high priced.'22 Leo Tolstoy, who was deeply suspicious of medical science had a strong dislike for medical doctors and a pathological obsession with the 'indecency' of the physical examination. Pozdnychev in The Kreutzer Sonata23, who tells a chance acquaintance on a train how he had murdered his wife, complains bitterly about 'doctors who cynically undressed her and felt her all over - for which I had to thank them and pay them money ... I understand they want to earn money like lawyers and others' but somehow this character (and Tolstoy) seem to resent physicians' fees to a greater extent than those ofother professionals. Dr Daneeka in 'Catch 22', like Chaucer's physician, has a kickback fee arrangement with drug stores2A. Unlike the other characters in the book who worry about staying alive or engage in personal squabbles with fellow members of the military establishment, Doc Daneeka spends most of the war brooding about his loss of income. 'I don't want to make sacrifices, I want to make dough'25. Despite the great diversity of these passages a common theme runs through them all. Pindar and Proust, Geoffrey Chaucer and Joseph Heller (not to mention contemporary journalists) all appear obsessed with the doctor's payment, his wealth and his greed. This sentiment is so deeply entrenched that there are even suggestions that the atypical physician who is not interested in money can not be any good at his job. 'A physician who heals for nothing is worth
nothing'26. *
Dostoyevsky deliberately contrasts two medical practitioners. The local physician was a 'kind-hearted, humane man who treated his poor patients .. for nothing, went into their hovels . . . left money for medicine'27 but his visits 'were of little avail'28. On the other hand, the famous Moecow specialist who was obviously contemptuous of the Snegiryovs and their poverty and who bellowed in 'a loud peremptory voice' had come over 'for a large fee' 29. Lawrence Sanders30 tells of an encounter between Captain Edward X Delaney, a senior New York police officer and a Dr Spencer who informs him that his wife will have to have an operation on her kidney. 'Do you anticipate any trouble, doctor?' he asked. The surgeon ... looked at him coldly. 'No' he said. (Dr Spencer subsequently performed a nephrectomy and Mrs Delaney died as a result of a Proteus infection). 'I tut him' Delaney said . . . 'He's a professional. I asked Ferguson to check him out and he said Spencer is a fine surgeon and a wealthy man'. 'Good' Barbara smiled faintly, 'I wouldn't want a poor surgeon' 3. *This statement which is often quoted out of context comes from a passage describing how a successful plaintiff in an assault case may foil a dfdendant's attempts to minimize his medical costs. Ifthe defendant (presumably a physician who injured the plaintiff in the first instance) offers to treat him himself, the plaintiff is entitled to reject this 'generosity'. If the defendant tries to introduce the injured individual to a physician who will treat him free of charge the plaintiff may counter by saying a physician who charges no fee is worth none. If the defendant proposes to bring a physician from out of town the plaintiff has the right to refuse this offer alsof.
Journal of the Royal Society of Medicine Volume 85 January 1992
This brings up the question of why the physician's 7 Wycherley W. The Country Wife (1675). In: Friedman A, ed. The Plays of William Wycherley. Oxford: Clarendon fee should be resented and commented on any more Pij 1979;24&44 disparagingly than that of the builder or the 8 Dickens C. The Life and Adventures ofMartin Chuzzlewit dressmaker. Why should an appropriate remuneration (1844). London: Oxford University -Pres 1959:437 be considered incongruous in a doctor? Fiction writers 9 Malory T. Le Morte D'Arthur (1485). London: Dent, do not address this problem specifically but here 1938:40-2 and there one can find hints. The priest-like figure 10 Chandler R. The Little Sister (1949). In: The Chandler with his ritual, his vestments and his specialized Collection, vol. 1. London: Picador, 1983:424 vocabulary, with his ability to examine body and sQul 11 Stevqn- RL. The Strange Case of Dr Jekyll and suddenly becomes a common tradesman when he Mr' Hyde (1886). London:'Heinemann, 1924 demands a fee. 'We are angels when we come to mire, 12 Knox R. Studies im the Literature of Sherlock Holines. In: Haining P, ed. A Sherlock Holmes Compendium, devils when we ask for payment'31. London: W. H. Allen, 1980:47-65 Demanding a fee might-be appropriate behaviour 13 Forster EM. Passage to India (1924). London: Penguin, for a barber surgeon (a once-off fixer), a dentist or an 1988 apothecary. It might even be appropriate for a 14 Cousins N, ed. The Physician in Literature. Philadelphia: 19th century medical practitioner who supplied his 1982 Saunders, patients with 'pink and browu mixtures'32 and Who 15 Hill J. The doctor as hero in nineteenth century British provided 'somethingmeasurable' for which he could. fitioti, The- Pharos of Alpha Omega- Alpha 1987:50; submit an itemized account32. It; is evidently. con, 31-33 sidered inappropriate for -the physicianl. who tis 16 Belloc H. Cautionary Verses. Edinburgh: Duckwortb/ perceived to function as a hybrid betwee. aGoa Nelse, 1940:18-19Samaritan and a Faustiai -seeker- of knowledge -j 17Z Pindar, Pythian Odes (approx. 474 BC). In: San"dys J, trans. The Odes of Pindar. London: Loeb Classical The problem is discussed in considerable4detailby Ibray, Heinema, 19$i8:189-91 Anthony Trollope. Doctor Thorne33Sb aroused the 18 Chaucer G. Canterbury Tales (approx. 1390) In: Fisher displeasure of his 'Barchester' colleagues by charging JH, ed. The Complete Poetry and Prose of Geoffrey somewhat less than the coxou.fee aMl; by actuallyCh&$er.- ew York: H1lt, iThineiart and''Winston, fishing around in his trousdrpcketfurthe uWcessary 1927':17-1A t,, change after a consiltatien.-'A physician should take 19' Shakespeare W. In: Wright LB, la'MarVA, s. The his fee without letting his left hand know -what his, -lage& of Macbeth (1606), Adt V, Scenes I AnlIl. New right hand was doing. It should be taken without a York: Wahington Squrare Presh, 1969077-84 thought, without a look, without a move of the facial 20 Turgenev I. The Diatrict D)octr (1852). In: Garnett C, tra8sl. The Novels of Ivan Turgenev,- vol. 1. London: muscles. The true physician should hardly be aware -Hei!nem n, 1920:56 that the last friendly grasp of-the hand had been made 21 Proust M0. In: Scott-Moncrieff CK, Kilmartin T, more precious by the touch of-gold'33 transl. Remembrance of Things Past (1913-1922). Somehow we are all onscious of these.sentiments HarmondsWorth: Penguin, 1987:Vol 2;354-5 and the medical profssio emhploys tens of thousands 22 Mann T. In: Lowe-Porter' HT, transl. Doctor Faustus of receptionists whose main function is to separate the 1947. 1ondon: Secker-and Warburg, 1949-475-6 'handshake' from the 'gold'. 23- Torsty L. The Kreutzer Sonata (1891). In: Maude A, rtranol. Leo Tolstoy, Short Novels vol 2. New !York: SolomPn Posen Medern Library odooe, 1966:148-9-Nor,th $here MVedicul ,Centre - 24 ReAer. J. Catch 22 (1962). New York: DelL Publishing 66 Pacific, Highway, S Leonmrds 2065, q,,974:41 Australia 25 Ibi, p 33. 26 Kirner EW, transl. Epstein I, ed. Babylonian Talmud, References Baboc Kamma (approx.'450 AD) London: Soncino Press, 1 Jonson B. Sejanus His Fall (1604). In: Herford OH, 1964:85a Simpson P, eds. Ben Jonson, vol. 4. Oxford: Clarendon 27 Dostoyevsky F. In: Magarshak D, transl. The Brothers Press, 1966:379 Krazov (1880).- Hairmondswoth, UK: 1978:Vol 2; _
2 Behn A. Sir Patient .ancy (1678). In: Summers M, ed. The Works of Aphra &hn, vol. 4. New York: Pha6toni Press, 1967:98-107D 3 Sterne L. The Life and Opinions of Tristram-Shandy)
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4 Dickens C. Pickwick Papers.(1837). New York: Signet Classics, New American Library., 1964;726 5 Trollope A. Doctor Thorne (1858). London: Oxford
University Press, 1963:123 6 Melville H. White Jacket (1850). New- York: Grove Press, 1959:238
790 28 TIbid;p 633 29 Ibidp-B48; 30 Sanders L.; The Fir*Dwdly Sin. London: W, H Allen,
*1974;87 Scott W; The Abbot (1831). London: Adam and Charles Black, 1893:280 32 liot G. Middlemarch (1871-2). London: Penguin Books, 1988:484-485 33 Tr6llope' A. Doctor Thorne (1858). London: Oxford UJniversity Press, 1963:123
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