menuPaper: Knock or the triumph of medicine
04 November, 2003
At the University of Groningen in the Netherlands, general practitioners in training perform the play. In secondary schools throughout Europe that same play is read as a lesson in French, founded on a vocabulary of 1800 words.
The French actor Louis Jolivet became famous in the film version.
We are of course talking about Knock ou le triomphe de la médecine published by Jules Romains in 1924. It is a morality play for young doctors, a tool for mastering French for school children and popular comedy, still running in France.
Jules Romains, who died at the age of 87 in 1972, wrote his masterpiece ‘Les hommes de bonne volonté’, a portrait of a generation between 1908 till 1933 in 27 volumes. Like Voltaire’s Candide or Erasmus’ ‘In praise of folly’ only a small, slim booklet survived him.
However, it illustrates his conviction that the masses are indolent and without initiative, waiting for an animator to give a community new ideas and energy.
Dr. Knock, the main character in the play, is such an animator and causes a medical revolution in a sleepy village called Sainte Maurice.
Doctor Knock, with minimal medical qualifications replaces the old village doctor who believed that his patients would be cured by time and not by his medicine. In the afternoon he loved playing billiard in the café and talk about cars. He is in fact a therapeutic nihilist and longs for a big city. His successor Knock on the other hand thinks that healthy people are ignorant of their hidden maladies. He announces free consultations on Monday, puts every patient to bed in a quiet, dark room and gives him or her a strict diet. No one escapes his diagnostic eye that is immediately aware of a hidden disease and its possible grave consequences.
The local teacher is under pressure to teach hygiene at school, stressing the importance of microbes. The local pharmacist is told to double his income from Knock’s prescriptions and the fame of the new doctor is spreading beyond the village. The local hotel is fully occupied by the intake of patients from elsewhere, treated by a capable modern doctor.
One day the old doctor visits his successor. He is amazed by Knocks’ success but regards him a charlatan and moneymaker. Knock replies that his only plight is to serve modern science in the practice of medicine.
On a evening, after sunset, Knock shows the old doctor from the hotel balcony the village, which is half in darkness. In the other half of the houses, the lights are still on. Knock is telling his colleague that these lights come from the homes of his patients. When the clock strikes 10 they are all taking their temperature for the second time that day. They that sleep in darkness are the people who believe to be healthy but ignorant of their own diseases. Knock is aware of his medical powers and his ability to diagnose illness in a single look at his patients but finally it alarms him. He avoids looking in a mirror, in fear of detecting his own illness and becomes a victim of his own practice. ‘Le trompeur trompé’, the deceiver deceived is the message.
The author made Doctor Knock one of his animators who finally believed in his own inventions. The indolent village folk are easily led to accept his opinions on their health and diseases but there is justice when dr. Knock is not only perpetrator but a victim of his own mischief.
Jules Romains published the play in 1924, a year after insulin was discovered and long before modern medicine began with penicillin, polio vaccin and surgery of heart and brain.
A village doctor, at that time, had very few possibilities to cure and Knocks predecessor spent his time chiefly with his car and playing billiard, doing no harm. Doctor Knock changed all that by becoming an anxiety maker, sending people to bed on the slightest complaint. As a salesman he made a lot of money out of it, together with the pharmacist and Madame Remy who converted her small hotel to a fully occupied hospital.
What can we learn from Doctor Knock and the way he practices medicine?
Is he a fictional character from a different century or does he live among us in different disguises?
I believe the latter is true, even when our own, effective modern medicine is so different from Doctor Knocks world. Like the good people of St. Maurice we expect wonders and hope for the impossible, the wonder cure. In those expectations we are often irrational, taken in by medical salesmanship and advertising or in the grip of unreasonable fear.
Our world is not so different from Doctor Knock’s maxim that people that feel well are patients ignoring their illness. Although our health statistics in Western countries demonstrate our health and longevity many people are worried about their health and fear their mortality.
Let me therefore introduce some latter day Doctors Knock.
The subtle ones are epidemiologists who find some correlation between e.g. diet and cancer. It is then trumpeted as a possible cause and we are admonished to eat fruit and vegetables or avoid meat. It is an aspect of medicalization, measuring our daily doings exclusively with the yardstick of being healthy because we are threatened by many known or supposed risk factors.
A more brutal approach by gynaecologists is considering women after their menopause as patients, liable to bone fractures, heart disease and other ailments, to be prevented by decades of oestrogen suppletion. The doctor, the pharmaceutical industry and health information services , all profit from this propaganda, like Doctor Knock, his pharmacist and school teacher. The scale, however, has expanded enormously as compared with St. Maurice.
The facts are that hip fractures occur, mostly in women in their eighties, are related to accidents like a slippery floor and less to the degree of osteoporosis. Oestrogens promote uterine cancer and progesterone has to be added to regimen to prevent this. Heart disease is not prevented, breast cancer may increase like venous thrombosis and embolism but the promise of oestrogen replacement by keeping women young, feminine and with healthy bones is propagated everywhere.
Dr. Knock has a more insidious role in mental health.
Many young people feel tired, suffer from repressed memories, have varied physical symptoms after wars, disasters and life events like divorce, unemployment or loss of family. The chronic fatigue syndrome is such an expression, by its sufferers attributed to a virus that attacks their muscles and brain; a burn out or a whiplash are other examples.
By defining these vague and variable symptoms as a distinct disease entity people are converted into chronic patients, in need of treatment, social benefits and are declared invalids.
Daily life events are brought under medical scrutiny for early detection of lurking disease. There is great enthusiasm for population screening and the early detection of breast cancer would be a justifiable method. Until now, however, a clear and important effect has not been demonstrated and, as with all screening, a lot of anxiety is generated.
Many individuals, especially in the United States, want their cholesterol or prostate enzymes measured, ask for a coloscopy every two years and undoubtedly genetical risk factors will be determined in healthy people. We live in fear of disease and death and medicalization drives us to the belief that in the end we are all patients.
The money at stake is enormous and so are the dangers of overdiagnosis and overtreatment.
If conventional medicine cannot deliver results there is the bypass of alternative medicine.
In the Netherlands some 25 percent of patients with serious disease like cancer, multiple sclerosis, aids and others use alternative methods next to their regular treatment. They may rationally not believe in a cure by magic but want to try everything that claims to help. The use of vitamins in the Netherlands suggests that we are a country beset by beriberi, night blindness and scorbut.
Finally, what can we learn from Doctor Knock?
First of all, that medicine has the plight to be honest about its claims and pretensions. Despite many great successes there are still incurable diseases, only partly understood and without promise of treatment like schizophrenia, dementia, multiple sclerosis and rheumatic disease. Many solid tumours like lung cancer are barely treatable and in the wider world tuberculosis, malaria and aids are spreading rapidly. An open and honest dialogue with society about what medicine can achieve is necessary.
Secondly, if we grant people, patient and healthy ones alike, self determination we should give them choices, based upon non biased information, if informed consent has any meaning.
Lastly, we should be willing to look at our practice because, as the famous clinician Osler said a century ago, ‘medicine is a science of uncertainty and an art of probability’. The pretension of medicalization, of having a cure for all ills present or in the future leads to self-deception, bad medicine and quackery.
Let us leave Doctor Knock in Saint Maurice and let us use his example as a morality play for young doctors or a tool for mastering French.
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