Grand Rounds in Literature - Original Essay

Ambrose Bierce and the Devil's Dictionary
by Clifton R. Cleaveland, MD, MACP

Tennessee ACP Chapter Meeting
Nashville, 11 March 2002

Consider a sampler of terms from The Devil's Dictionary by Ambrose Bierce:

Physician - one upon whom we set our hopes when ill and our dogs when well.

Our profession was not the only one to earn the attention of the 19th century's most accomplished American satirist.

Dentist - A prestidigitator who puts metal into your mouth and pulls coins out of your pocket.

And then there were lawyers; lawyer - one skilled in the circumvention of the law. And litigation - a machine which you go into as a pig and come out as a sausage.

Bierce saved his most pointed arrows for practitioners of the noble art of politics, defining a politician as an eel in the fundamental muck upon which the superstructure of organized society is reared. When he wriggles he mistakes the agitation of his tail for the trembling of the edifice. As compared with the statesman, he suffers the disadvantage of being alive. Politics comes off as a strife of interests masquerading as a contest of principles. The conduct of public affairs for private advantage.

In light of Enron, Worldcomm, Tyco and other megabusinesses recently fallen from grace, listen to Bierce's definition of the corporation: an ingenious device for obtaining individual profit without individual responsibility.

Who was this practitioner of such audacious calumny? Ambrose Bierce was born 24 June 1842 in the backwoods of Southeastern Ohio, the tenth of thirteen children. His father, Marcus Aurelius, insisted upon naming each child with a name beginning with the letter "A." The family lived in desperate poverty. In a childhood marked by unrelenting duty to parents, farm and fundamentalist church Ambrose did find time to read voraciously.

At fifteen he left home to become first a printer's devil. Next he spent a year at the Kentucky Military Institute before enlisting in 1861 in the Union Army. He found a home in the Army and rose to the rank of brevet major by war's end. He fought in the battles of Nashville, Chickamauga, and Kennesaw Mountain where he was shot in the head, the bullet penetrating his skull and coming to rest behind his ear. After a brief convalescence he returned to combat, was captured, escaped and served to until the war concluded. After a stint working for the US Treasury Department in Alabama, he joined a military expeditionary force sent to explore the territory lying between Nebraska and California.

Reaching San Francisco, he resigned from the army and took a job as a night watchman. He had decided to become a writer, and after extensive practice while on the job, he found markets for his various prose pieces in San Francisco publications. His pungent prose soon appeared in the papers and magazines of Eastern cities. In 1871 he married wealthy Mollie Day, whose father financed a trip to London for the couple on the condition that they would take Mrs. Day off his hands. There the threesome would remain for four years. Ambrose found ready markets for his prose in British periodicals. Commissions, however, were insufficient to support him. After his return to America Bierce worked in the US mint until he could establish literary connections. Eventually he would compose columns for three San Francisco weeklies. William Randolph Hearst hired the fiery journalist to write a weekly column for the San Francisco Examiner. He reveled in exposing fools and foolishness. He composed verse, satiric fables, essays, and short stories. He carefully cultivated a talent for making enemies in the same fashion as H. L. Menchen decades later. Bierce collected some of his favorite barbs in The Devil's Dictionary.

Always restless for adventure, Bierce set out in 1913 for Mexico to join the army of Pancho Villa. His exact fate remains unknown. The movie, The Old Gringo, wonderfully captures the man and the times.

In honor of Ambrose Bierce, who after all, came through our part of the country, I thought it only fitting to update The Devil's Dictionary in light of some of the terminology and its purveyors whom we daily encounter.

Let us begin with capitation - a noun, an advanced mathematical concept by which the health care dollar is divided into three equal halves, one to be allocated to administrators of various stripes, one to sellers of hospital services and medications, and one to remain in perpetual flux, only occasionally showing up on the balance sheets of physicians.

From capitation it is easy to move to precertification - a noun, an administrative structure designed to assure that medical care is more likely to be less timely.

We are clearly on a roll now. Captitation and precertification are fundamental to HMO - a noun, derived from the term HUMONGOUS to denote the unrestrained power of a system designed to trash the doctor-patient relationship.

Another derivation is HIPPA, the newly released set of regulations dealing with confidentially of clinical records. Our updated Devil's Dictionary would see this as a noun, an abbreviation of HIPPOPOTAMUS, designating a large clumsy entity that mindlessly stomps all in its way.

Instead of limiting our barbs to corporate and governmental enterprises, let us consider some of our own.

RK or radial keratotomy - noun, procedure for correcting myopia so that the charge for the procedure can be read by the patient without glasses before he swoons; alternatively, an income redistribution technique permitting the purchase of vacation homes by ophthalmologists.

And how about Botox, another noun, substance that smoothes wrinkles out of overfilled billfolds of patients. From Bo Derek, sometime movie actress.

And while we are in the area of plastic or aesthetic surgery, there is liposuction, a noun, technique for debulking a hulk; alternatively, a French kiss.

MRI in our updated dictionary becomes, abbreviation for Mighty Reimbursement Machine.

In the vocabulary of our daily work, we find unformed stool - a noun, furniture kit from Crate and Barrel.

And guaiac - failed line of General Motors automobile named for Indian chief of same name.

Scientific progress necessitates the creation from time to time of new subspecialties. Certainly it is time to recognize procto-ophthalmology - subspecialty dealing with visual handicaps of Medicare administrators.

Ranging further afield, how about mural dyslexia - a noun, the inability to read the handwriting on the wall when one's back is up against it.

I have saved the most difficult etymology to last, namely TennCare. Many people erroneously assume the Tenn in TennCare is an abbreviation for Tennessee. This is definitely not the case. My initial research suggested that "Tenn" came from "tenaculum"-the small, sharp-pointed hook set in a handle, used for seizing and picking up parts in operations and dissections. Certainly the sharpness and the seizure are appropriate to the insurance plan. Further study produced "tentative"-meaning experimental, done as a trial or attempt. That derivation of the "Tenn" is quite apt. Finally, reference to ancient manuscripts indicated quite clearly that "Tenn" was short for "tenesmus"-a straining to defecate or uninate without the ability to do so. Combining the three origins I propose TennCare, a noun, a sharp-edged experiment in the financing of health care, characterized by much straining but with no delivery.

So what is my point? In the latter decades of the 19th century, Ambrose Bierce looked at the explosive growth and chaos as the new city of San Francisco changed from trading post to burgeoning metropolis. He looked beyond facades of wealth and fashion to call attention to people left behind. His enemies were pomposity, arrogance, and mindless bureaucracy. His allies were common people.

Healthcare in our day exhibits similar exuberant and chaotic growth. Finite energies and dollars routinely are squandered in supporting administrative structures that serve neither the interests of patients nor those seeking to care for them. Fortunes are made in the health care industry, yet many of our fellow citizens find it ever harder to obtain basic medical care, and indeed many good practitioners who find their fulfillment in caring for the sick and injured are driven crazy by mindless regulations.

Satire allows us to pause, to take notice, to scoff if necessary. Satire allows us to separate substance from the ephemeral. Satire can expose the emperor when he has no clothes. Satire when combined with reasoned, clearly articulated arguments on behalf of our patients and our basic ethical concerns as physicians can arrest the steady erosion of health care by forces more interested in wealth than in health.