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 consulted faith healers with the same enthusiasm she showed for patent medicines and hydrotherapy; the young Clemens accompanied his mother on visits to a self-proclaimed "faith doctor," a farmer's wife who cured Mrs. Clemens' toothaches by putting a hand on the patient's jaw and exhorting "Believe!" [12, 19]. Later, Twain became even more familiar with faith healers through the medical experiences of his wife, Olivia Langdon Clemens. At the age of 16, she was injured after falling on the ice and was unable to get out of bed for 2 years (historical accounts have hinted at the possibility of hysterical paralysis).

"All the great physicians were brought to Elmira one after another during that time, but there was no helpful result. In those days both worlds were well acquainted with the name of Doctor Newton, a man who was regarded in both worlds as a quack. He moved through the land in state; in magnificence, like a potentate; like a circus. Notice of his coming was spread upon the dead walls in vast colored posters, along with his formidable portrait, several weeks beforehand [20]."

Newton, who had been "Practicing upon the well-to-do at war prices and upon the poor for nothing," was summoned to the young woman's bedside, where he

"opened the windows-long darkened-and delivered a short fervent prayer; then he put an arm behind her shoulders and said, ‘Now we will sit up, my child.’"

"... Then Newton said, ‘Now we will walk a few steps, my child’ ..."

"His charge was fifteen hundred dollars and it was easily worth a hundred thousand. For from the day that she was eighteen until she was fifty-six she was always able to walk a couple of hundred yards without stopping to rest."

"... I met Newton once, in after years, and asked him what his secret was. he said he didn't know but thought perhaps some subtle form of electricity proceeded from his body and wrought the cures [20]."

Therapeutic Equivalents: Unregulated and Ineffective Medical Systems

Diversity in medical care systems was promoted by the political forces of the early 19th century. There was widespread resentment of special privilege in the era of Jacksonian democracy (the era of "the people"), the 1820s and 1830s [14]. Laws controlling medical practice were viewed by the public as a form of class legislation; a general belief that citizens should have the right to choose their own medical care was combined with a distrust of the motives of regular physicians [21, 22]. When newer sects, such as botanical medicine ("herb doctors"), petitioned for recognition, state legislatures such as the one in New York took a radical approach. Rather than recognize the new groups, they explicitly repealed previous laws granting special privileges to the regular physicians, thereby making medical licensing irrelevant [14]. Control of medical licensure by state legislatures had almost disappeared by 1850, and the resultant "free trade in medicine" allowed anyone to practice medicine, regardless of qualification or training [14]. Medical deregulation even progressed to the point where it was legal for any citizen of Maryland to charge for medical services [22]. Confused and dissatisfied patients were forced to choose between the excesses of allopathic medicine and the conflicting claims of its numerous unregulated competitors. The result was medical anarchy.

Twain had no difficulty describing the shortcomings of each of the various medical approaches available in this unregulated era. Allopathic medicine was notable for its heroic and toxic treatments.

"[I]f a citizen was inclined to take salts by the ton, ipecac by the barrel, mercury by the quart, or quinine by the load, and thus be cured of his ailment or his sublunary existence by the wholesale, he was at perfect liberty to invite he services of a medicus of the allopathic style ... [23]"

Homeopathic medicine, using infinitely small and diluted doses of agents that mimicked the disease being treated [14, 15], was the essence of nontherapy.

"[I]f another citizen preferred to toy with death, and buy health in small parcels, to bribe death with a sugar pill to stay away, or go to the grave with all the original sweetners undrenched out of him, then the individual adopted the "like cures like" system, and called in a homeopath physician as being a pleasant friend of death's [23]."

Alternative approaches, such as hydropathic medicine, appeared equally ineffective [23].

"Citizens there were too, who liked to be washed into eternity, or soaked like over-salt mackerel before they were placed on purgatorial gridirons, and these, "of every rank and degree", had the right to pass their few remaining days in an element that they were not likely to see much of for some time."

Twain was intrigued by those who combined features of all of the available treatment programs [23].

"Then again there were those who saw "good in everything" and who believed that whatever is is right and these last mixed the allopathic, homeopathic, and hydropathic systems, qualified each with each, and thus passed to their long homes, drenched, pickled, sweetened, and soaked."

In the absence of any rational or effective philosophy of medical care, the various health care sects were competitors throughout most of the 19th century. This state of medical disorder indirectly provided the impetus for Flexner's critique of medical education in the United States.

Limiting the Choices: Twain versus the American Medical Association

Although the Flexner report is frequently portrayed as the stimulus for a startling new paradigm for medical education that arose abruptly in 1910, this report was only one component of a social and political movement that had started years earlier. This movement, which was aimed at decreasing competition in the medical marketplace, can be traced back to the founding of the American Medical Association (AMA) in 1847 [2]: Opposition to competing medical systems became the AMA's major focus: The organization described the practices of opposing sects as "quackery," and its first action was to ban referrals to lay healers and nonorthodox physicians, such as homeopaths [24]. The establishment of the AMA may have been a political response to the foundation of the American Institute for Homeopathy in 1844; homeopathic medicine was the chief competition for allopathic medicine, and homeopaths were positioning themselves to control the U.S. medical establishment [2]. Although the constituency of the AMA was small (fewer than 7% of U.S. "healers" were AMA members in 1900), its membership included many well-educated physicians who had had postgraduate training in Europe and many who were affiliated with hospitals as researchers and educators. Allopathic physicians began to refer to their type of practice as "scientific medicine" to differentiate themselves from the "quacks" [2]. From its start, the AMA promoted educational reforms that tended to promote its own type of medical practice as the only legitimate one.

On the basis of his knowledge of the various sects of medical practice that coexisted throughout the 19th century, Twain did not believe that any single school of medical thought was superior, and he opposed any governmental restriction of the patient's options. Twain wrote to the New York Sunday Mercury in 1867 to protest New York governor Reuben E. Fenton's decision to favor allopathic medicine over homeopathic and hydropathic medicine by appointing three allopathic physicians to the four available positions on the Metropolitan Board of Health for New York City [25]. In stating his opposition to government intervention in health care, Twain [23] warned that

"the mania for giving the Government power to meddle with the private affairs of cities or citizens is likely to cause endless trouble, through the rivalry of schools and creeds that are anxious to obtain official recognition, and there is great danger that our people will lose that independence of thought and action which is the cause of much or our greatness, and sink into the helplessness of the Frenchman or German who expects his government to feed him when hungry, clothe him when naked, to prescribe when his child may be born and when he may die, and in fine, to regulate every act of humanity from the cradle to the tomb, including the manner in which he may seek future admission to paradise."

Twain argued for the preservation of diversity in medical treatment options [23].

"[T]here has always been a variance of choice under which system a citizen preferred to find his way across the Styx, and he enjoyed in this State till now the privilege of choosing the rower who was to aid in ferrying him over in Charon's boat."

However, the AMA continued to fortify its position by exerting increasing influence on the educational and licensing regulations that were the underpinnings of the medical system. With the new licensing laws of the 1890s, AMA members (with their backgrounds as educators and researchers) readily gained seats on the licensing boards. State licensing examinations began to favor allopathy over homeopathy by emphasizing the basic sciences (which were essential to the principles of allopathy) over therapeutics and materia medica (which were the basis of homeopathy), and the AMA's control over the licensing boards eventually brought the pluralistic system of medical care in the United States to an end [2].

This edging out of the medical competition continued into the new century through the process of educational reform. The AMA formed a Council of Medical Education in 1904, and in 1906, this Council surveyed all U.S. medical schools and graded them on various criteria, including such subjective items as "character of the medical curriculum" [2]. Later, the Flexner report was proposed by the AMA. Underwritten by the Carnegie Foundation, this report continued the process of weeding out competition by identifying the weak, commercially oriented schools that accepted poorly educated students, had trivial or nonexistent affiliations with colleges and universities, and had woefully inadequate resources [1]. Even though the number of U.S. medical schools decreased from 131 to 81 through the 12 years after the publication of the Flexner report [1], the influence of the licensing boards had caused a net loss of 34 schools during the 6 years that preceded the report [2]. Even earlier, several sects had been eliminated by legislative reforms enacted after 1870 [22]. Thus, the Flexner report was anything but an abrupt departure from the status quo. Instead, it was a "catalyst of a reaction long in the making" [1], one more step in the AMA-promoted restriction of medical ideology to that of the "scientific" allopathic school [2, 26]. The report may have been more of a public relations success than an intrinsic contribution to medical education [21].

During the era in which allopathy was successfully beating back its traditional competitors, a new form of competition-osteopathy-was developing. From its beginnings in 1892, osteopathy had been based on manipulative treatment (although contemporary osteopathic medicine is now almost indistinguishable from allopathic medicine [[27]). Twain was a strong supporter of this new movement, possibly because its manipulative treatments alleviated his daughter Jean's problems with epilepsy and his own chronic bronchitis [28, 29]. Twain's tradition of supporting the underdog may have been another factor in his support of the osteopathic movement; in 1901, he told the Committee on Public Health of the New York General Assembly that "I don't know as I cared much about these osteopaths until I heard you were going to drive them out of the state, but since I heard that I haven's been able to sleep" [13]. As he spoke in favor of licensing for osteopaths before the Committee, he was vigorously attacked by five physicians from the New York County Medical Society; he subsequently complained [13] that

"[t]he physicians think they are moved by regard for the best interests of the public. Isn't there a little touch of self-interest back of it all?"

"... The objection is, people are curing people without a license and you are afraid it will bust up business."

As an advocate of this new treatment option, Twain suggested that "[t]o ask a doctor's opinion of osteopathy is equivalent to going to Satan for information about Christianity" [28], and he was pleased to note that "it has got itself legalized in 14 states in spite of the opposition of the physicians ..." [28]. Twain was philosophically opposed to the AMA's efforts to restrict competition, and through his support of osteopathy he sanctioned each individual person's freedom of choice in medical care [13]:

"Now what I contend is that my body is own, at least, I have always so regarded it. If I do it harm through my experimenting it is I who suffer, not the state. And if I indulge in dangerous experiments the state don't die. I attend to that. ..."

"So I want liberty to do as I choose with my physical body. ..."

The Art of Medicine and Nontraditional Therapies

By recognizing the failings of every available medical system, Twain came to suspect that the physician-patient relationship was a least as important as any particular medical ideology. Faith in the skills of the therapist has always been essential to the healing effort, but the "art" of medicine never seemed more critical as it did when the "science" of medicine was almost nonexistent. The role of the patient's belief in the therapeutic process was undoubtedly reinforced for Twain by his mother's and his wife's positive experiences with faith healers [19].

"No one doubts-certainly not I-that the mind exercises a powerful influence over the body. From the beginning of time, the sorcerer, the interpreter of dreams, the fortuneteller, the charlatan, the quack, the wild medicine-man, the educated physician, the mesmerist, and the hypnotist, have made use of the client's imagination to help them in their work. They have all recognized the potency and availability of the force. Physicians cure many patients with a bread pill; they know that where the disease is only a fancy, the patient's confidence in the doctor will make the bread pill effective."

"Faith in the doctor. Perhaps that is the entire thing. It seems to look like it."

But even as he recognized the importance of faith in the practitioner, Twain realized that faith alone could not compensate for intrinsically flawed treatment schemes. He did not object if patients sought help from nontraditional practitioners (especially if they derived some psychological benefit from doing so), but he did have concerns (still shared by present day physicians [[30]) about any restrictive treatment system that would confine patients to a single doctrine by forbidding the concomitant use of traditional medical therapies [19].

"Within the last quarter of a century, in America, several sects of curers have appeared under various names and have done notable things in the way of healing ailments without the use of medicines. There are the Mind Cure, the Faith Cure, the Prayer Cure, the Mental Science Cure and the Christian Science Cure ..."

"They all achieve some cures, there is no question about it; and the Faith Cure and the Prayer Cure probably do no harm when they do no good, since they do not forbid the patient to help out the cure with medicines if he wants to; but the others bar medicines, and claim ability to cure every conceivable human ailment through the application of their mental forces alone. They claim ability to cure malignant cancer, and other affections which have never been cured in the history of the race. There would seem to be an element of danger here. It has the look of claiming too much, I think."

Conclusions

In the final analysis, Twain believed that some salutary features could be found in most of the medical movements of the pre-Flexnerian era, and he opposed the restriction of medical care options. One of his own physicians, Cincinnatus Taft, may have been a model for this conviction; although Taft practiced homeopathy, his obituary stated that "he exercised a certain eclectic independence, which looked rather to cure than to creed, and was not entirely within the limitations of any one school" [31]. Eventually, however, Twain became a proponent of the scientifically based direction that allopathic medicine was taking toward the end of his life, and he praised the contributions to medical science made by such persons as Pasteur, Jenner, and Semmelweis [32]. He considered the New York Postgraduate Medical School to be "one of the two greatest institutions in the country" because of its activities in providing continuing medical education for physicians [8]. As he summarized the advances in medical treatment that he had seen throughout his lifetime, it was clear to Twain that the introduction of a scientific approach to medicine had reformed the profession more than legislative mandates or political maneuvering had. In 1890, well before the publication of the Flexner report, Twain celebrated the impressive changes occurring in medicine in the United States [11]:

"Nothing is to-day as it was when I was an urchin; but when I was an urchin, nothing was much different from what it had always been in the world. Take a single detail, for example-medicine. Galen could have come into my sick-room at any time during my first seven years-I mean any day when it wasn't fishing weather, and there wasn't any choice but school or sickness-and he could have sat down there and stood my doctor's watch without asking a question. He would have smelt around among the wilderness of cups and bottles and vials on the Table and the shelves, and missed not a stench that used to glad him two thousand years before, nor discovered one that was of a later date. He would have examined me, and run across only one disappointment-I was already salivated; I would have him there; for I was always salivated, calomel was so cheap. He would get out his lancet then; but I would have him again; our family doctor didn't allow blood to accumulate in the system. However, he could take dipper and ladle, and freight me up with old familiar doses that had come down from Adam to his time and mine; and he could go out with a wheelbarrow and gather weeds and offal, and build some more, while those others were getting in their work. And if our reverend doctor came and found him there, he would be dumb with awe, and would get down and worship him. Whereas if Galen should appear among us today, he could not stand anybody's watch; he would inspire no awe; he would be told he was a back number, and it would surprise him to see that that fact counted against him, instead of in his favor. He wouldn't know our medicines; he wouldn't know our practice; and the first time he tried to introduce his own we would hang him."

Even as Twain ridiculed the unscientific approaches taken by practitioners of hydrotherapy and homeopathy, he continued to defend the importance of medical freedom of choice. He particularly recognized the importance of the competing systems in pressuring allopathic medicine to evolve into a new scientific discipline far removed from its noxious origins as a sect based on bloodletting and remedies such as Aqua Limacum (a concoction containing herbs, snails, earthworms, "Goose Dung," "Sheep Dung," "Strong Ale," and "Shavings of Hartshorn" [11].

"When you reflect that your own father had to take such medicines as the above, and that you would be taking them to-day yourself but for the introduction of homeopathy, which forced the old-school doctor to stir around and learn something of a rational nature about his business, you may honestly feel grateful that homeopathy survived the attempts of the allopathists to destroy it, even though you may never employ any physician but an allopathist while you live."