Popular Science Monthly/Volume 21/September 1882/The Physician of the Future
A CHANGE in the theory of disease, which long since began, but is not yet completed, must profoundly affect the work of the physician of the future. Disease was formerly believed to be a something which had a sort of independent existence, and which went about over the earth seeking whom it might assail. When this something had entered the body of a man it created confusion in his internal economy, and order could not be restored until the intruder was driven out. Accordingly, remedies none of the gentlest were vigorously applied until the disease was scared away or the patient died. It is strange how universal among men this belief in a possession, an entrance of something into the body causing disease, has been.
This savage idea was long perpetuated among civilized people, and remedies were used which were hardly less absurd than the leapings, howlings, and rattle-shakings of an Indian medicine-man. The change has come very gradually. At first the student of medicine enlarged his field of study, from disease and its phenomena, until it included the structure and action of tissues and organs in health. Physiology and anatomy, of little importance in the old science of medicine, began to have recognized value. After this it was found that organs did not always become disordered because of assaults from within the body, but that they were affected by external influences.
It was found that the organs must not only preserve equilibrium within the body, but that there must also be equilibrium between the body and its externals. It was discovered that in every organ there were forces that built up and forces that pulled down, and that outside of it there were also conservative and destructive forces, and it became obvious that, unless these acted so as to preserve equilibrium, disease, and finally death, must ensue. Thus the art of healing and the science of medicine are now very far from being as simple as they were a century ago, and every year adds to their complexity. The physician of to-day must have full knowledge of man as man, of anatomy and physiology, as a necessary foundation upon which his further studies must rest.
Physiology especially has developed during the last fifty years, so that it has almost become a science by itself, but it still remains a part of the wider science of biology. Here again we see a difference between the studies of the ancient and modern physician. To-day, and still more in the near future, the physician must extend his studies beyond man, and the reason is plain. Man, with whom alone the physician formerly supposed himself concerned, is but an isolated being disconnected from the rest of nature. Nature tolerates no such isolation. No living being, even the simplest, exists, or can exist, independently of other beings. It affects them and is affected by them, and what is true of the simplest is yet more true of the more complex and most of all of man. Nature is one, and all her creatures are parts of the whole. For this reason man can not be fully known merely as man, he must also be known as a part of the animal kingdom. No one can well understand human anatomy or physiology who knows nothing of that of the lower animals. Comparative anatomy and physiology have thrown very much light upon many obscure problems to which the study of man gave rise. Therefore, I would most earnestly urge upon all medical men the study of biology. It may be replied that the courses of study are now crowded, but it is certain that the successful physician of the future must know something of nature as a whole. Already many of our most important theories as to disease—the structure of organs, cell-growth, cell-life, and many more—have come to medicine from biology. In an address before the International Medical Congress held in London in August, 1881, Professor Huxley remarks that " the search for the explanation of diseased states in modified cell-life, the discovery of the important part played by parasitic organisms in the etiology of disease, the elucidation of the action of medicaments by the methods of experimental physiology, appear to me to be the greatest steps which have ever been made toward the establishment of medicine on a scientific basis. I need hardly say, they could not have been made except for the advance of normal biology. There can be no question, then, as to the connection between medicine and biological science. There can be no doubt that the future of pathology, of therapeutics, and therefore of practical medicine, depends upon the extent to which those who occupy themselves with these subjects are trained in the methods and impregnated with the fundamental truths of biology. And I venture to suggest that the collective sagacity of this congress could occupy itself with no more important question than with this: How is medical education to be arranged, so that, without entangling the student in those details of the systematist which are valueless to him, he may be enabled to obtain a firm grasp of the great truths respecting animal and vegetable life without which, notwithstanding all the progress of scientific medicine, he will still find himself an empiric?"
The modern theories of evolution have done great things for medicine, and will do far more in the future. They have put in action forces that may revolutionize medical science. Evolution has shown, as nothing else could, how profoundly animals are affected by their environment, their food, habits, climate, etc., and, by showing how inevitable is the modification of structure in other animals, has called attention to the same facts in man's existence.
Men knew long ago that animals were greatly affected by their surroundings, but this truth was far from being fully recognized until evolution re-affirmed it, and emphasized its affirmation by facts which could not be passed by. Thus man was led to ask, What application have these principles to my own habits of life, to my well-being? To what extent are my diseases induced and fostered by external conditions? The reply to these inquiries is found in sanitary science, in health officers and boards of health, and we have as yet only the beginning of the answer. Sanitary science, though in its infancy, has already profoundly affected medical science in many directions. Perhaps the most important effect that as yet appears is the leading medicine away from its old, blind, absolute faith in remedial agents, in therapeutics, toward greater faith in right living, proper diet, dress, and drainage. Not that remedies are to be wholly laid aside, but they will be more sparingly used, and more intelligently, and often not at all. Where formerly drugs, powerful in quantity and quality, were invariably given, many of our best physicians now prescribe few or none, depending, and with better results, upon pure air, simple food, and other hygienic means. I believe that more would thus treat disease were they not prevented by the patients themselves.
So long as it is less trouble to take quinine than to clear out drain or cess-pool, so long as men prefer swallowing drugs to abstaining from favorite articles of food, or regulating personal habits, so long must the medical advisers of a community find their best efforts to advance sound sanitary science thwarted. It will be a long and tedious task— this of educating out of the popular mind this strange passion for dosing; but herein lies one of the most important tasks of the physician of the future. If he does his work well, he must be strong enough and determined enough to stem a powerful current of deeply rooted prejudice and self-indulgent unreasonableness; but, if he and his fellows only persevere, they will do incalculable good. So difficult is this work that many shrink from it. They admit the importance of fresh air in hospitals, nay, they demand it, but in their private practice they say little about ventilation. They are careful that their prescriptions shall be properly compounded and regularly taken, but they are much less careful about the diet of their patients. They treat zymotic diseases, but do not enforce such sanitary regulations as they know to be necessary. I do not say that all are open to this charge—not all, but some—and there should be none. With all earnestness would I plead that the people be taught how to live, and I would urge this not only for the sake of the people, but for that of the doctors as well. It is evident that their success as healers of disease must be far greater if their patients observe hygienic laws than if they do not. The instructions of the doctor, weighty enough when given to one stricken with grave disease, may often fall unheeded upon the listless ears of a well person. Sick people are usually more eager to get well than well people to avoid sickness; and yet, even though the labor seem well-nigh useless, the welfare of the race demands that the principles of hygiene be made known, and the task of doing this naturally rests upon those who have undertaken to be the medical advisers of the community. It may be that the people will learn to care very much for those laws upon the observance of which good health depends, with discouraging slowness, but the good work once begun must go on with increasing power and influence. We may take heart as we see what has already been done in this direction, for a great deal of very important knowledge has already been received by the people—knowledge of the necessity for fresh air and sunshine, of cleanliness of person and of premises, of proper food, clothing, and exercise, of the laws of heredity and how hereditary tendencies to disease may be overcome. If we compare the sanitary condition of the homes and the villages of our ancestors not more than a century ago, with that which we may now find, we shall, I think, be led to hope very much for the future. It may still be true, as an eminent medical writer not long since declared it to be, that "men in general behave in relation to the laws which govern human evolution very much as primeval savages behaved in relation to the laws of physical nature—are content with superstition where they should strive to get knowledge, and put up prayers where they should exert intelligent will." This may be true, but it is certainly less true than formerly, and the physician of the future is to see to it that it becomes wholly untrue. If man can ever reach a time when epidemic diseases shall be of rare occurrence, when all zymotic diseases shall be confined within narrow bounds, and be speedily eradicated within these, he must remember with profound gratitude those to whom he owes his happy estate. Is there any other way in which the physician can so alleviate suffering and so help mankind as by striving to bring to pass such a blessed state of things? Is this too much to hope for? Possibly, but we may approach it much more nearly than we have as yet. Even in its beginning preventive medical science is far from a failure. Epidemic diseases that once raged as the pestilence are now largely prevented; others, once objects of unspeakable terror, are robbed of much of their virulence. Life-insurance statistics show us that human life in England is more than thirty per cent longer to day than it was one hundred and fifty years ago, and the end is not yet reached.
The relief of suffering, which is commonly thought to be the chief mission of the physician, is indeed a great and noble work, but I believe that he may do a higher and grander work. There are a pathology and a morbid anatomy, not of the body only, but of the moral nature as well. Many physical disorders are also moral and mental, and can only be rightly treated as this is understood. If it be true that men are not only more comfortable and happy when well than when ill, but that they are better morally, a new and most important field of usefulness is opened before the physician. If a well man, other things being equal, is a better man than a sick one, more certain to act wisely, to judge candidly and fairly, and live rightly—if a well man is of more worth in every way than a sick one—then all that has been said of the need and the value of hygienic instruction has added force. I do not for a moment forget the many heroic natures that have been grand enough to rise above bodily pain and feebleness, and with pathetic earnestness have sought to do some good work for the world, and have sent forth from their chambers of suffering golden words, melodious, heart-stirring verses, helpful soul-inspiring thoughts. And yet we need to recognize the fact that good is more certain to come from health than from disease. Pain may have its mission, physical and moral, and may bring out the richness and sweetness of a character as nothing else can, but in and for itself it is not desirable, and it can not be doubted that a community that is sound physically will be more sound morally than it could be if harassed by pain and weakness. I believe that there is such a thing as sin in the world, and I would not call it a disease for which man is not responsible; but none the less do I believe that physical disorder, that sickness and pain, morbid conditions of the body* causing morbid conditions of the mind, may and do lie at the foundation of very much that we call crime. A man whose digestive system is a continual scourge, whose nerves are weak or excited, whose brain receives impure blood, such a man can not be the same man morally that he would be were he in full vigor of health. Well men are not always virtuous. Ill health is not the sole cause of crime, nor can criminals be treated as invalids—not at all. And yet crime is often closely connected with disease. It is often both the parent and the offspring of disease. Since we may not know just how much of the crime in the world is due to pathological conditions of the body, we must punish crime as such, but we may, because of our doubt as to its cause, be liberal with our charity and lenient in our judgment whenever, and to such extent, as they may not interfere with the welfare of society as a whole.
No one holds a maniac morally responsible for his actions, even if grossly criminal. Is insanity the only morbid condition that dwarfs man's moral instincts, that blinds him to truth?
In this case we can see how much preventive measures are better than curative, and the future work of the physician, if it be largely the teaching people how to live so that they may avoid disease, must also lessen the amount of crime. It were well if the physician kept constantly before his mind the thought that he is to seek to make men better morally as well as physically. If it is better so to live that illness shall not come, than being ill to be cured, it is also a nobler and a higher task to prevent disease than to heal it, and in this labor of prevention medicine will rise to a height far above that to which it has yet attained, and accomplish results more beneficent and glorious than its greatest triumphs of the past.
And the whole community must be instructed—women more than men, for they more than men regulate the condition of the home. Upon them is laid not only the burden of bearing the children, but they most have to do with their food, clothing, and general training. And, since woman must take part in the great work of sanitary instruction, she should have a thorough medical education, that she may be able to tell to every woman, and every girl too, what she ought to know, and what she will not and can not learn so readily nor so well from any man.
If man were altogether an animal and had only animal instincts, there would perhaps be little ground for hope, but man can be taught not merely that he may so care for his body that it shall be less subject to the attacks of disease, he may be taught that it is his duty to so care for it that his physical organism is a God-given trust which he can not violate without moral wrong. The physician of the future must, as has been already noticed, have to do with the moral as well as the physical nature of man. But, before he can do this with success, he must understand what man is, his feelings, emotions, thoughts, as well as the course of the blood or the action of organs. If he shall know of this higher part of man, he may appeal to it forcibly and persistently. Anatomists and physiologists, as they study the body, may be so engrossed in the object of their investigations that they forget that it is not the whole of man. They may forget that this dead body which they study does not offer any explanation of the deepest and most conspicuous phenomena of human life and experience. The cadaver on the dissecting-table is not a man. Neither the anatomist's scalpel nor the histologist's microscope can ever discover what it was in that body which made it a man, distinct from other men.
The lips, tongue, vocal cords, are all there, but it was by these, not from them, that came the words of love or hate, entreaty or command, which the man spake during his life. The brain is there, it is or was the organ of the mind, but the thought—where is that? Evidently we have not here all that made this man a man, and we must see more than the body if we are to know man; we must see that in that body there was an essence—a something which we can not define, but which is as real as if most definite, and that this something, this soul, is far more important than any other part of man. When he stands over his dissecting-table, the anatomist may think of man as only an aggregation of organs and tissues, and these of differently arranged and modified cells; but when he sends his thought into the recesses of his own heart, when he calls before him the experiences of his inmost life, when he looks around him and sees men—their activities, struggles, defeats, triumphs, courage, even their meanness and knavery, and still more when he knows of their thoughts of the hereafter, their longings for something better and higher than this world can afford them—when, in short, he stands face to face with the phenomena of human life in its varied phases, is he not compelled to believe that it all must have some other source than the molecular and chemical forces which he finds in the body?
It is in this fact—in the existence of a soul in man—that the physician of the future must rest his hope of success. That man has in himself capacity for growth, that progress is and always must be possible to him—these are truths that must sustain the sanitary reformer in the midst of greatest discouragement. If it be true that man may live not only for the present, but as well for the future; if he can be made to see that he may not only make his present life better and nobler, but that in doing this he is affecting his future life; if he can be brought to understand that what he is in this life must necessarily determine largely what he is to be in the life beyond the grave; that, though the body is not the soul, yet, as the medium by which the soul manifests itself, its condition affects the soul—will he not be ready to listen to the teachings of any who can help him to a better physical and so to a better spiritual life? Only as the physician holds before his mind the whole of man can he reach the full development of his own life; only thus can he raise man to that height of, sanitary well-being: to which he should seek to raise him. In the address to which reference has already been made, Professor Huxley says: "A scorner of physic once said that Nature and disease may be compared to two men fighting, the doctor to a blind man with a club who strikes into the mêlée, sometimes hitting the disease and sometimes hitting Nature. The matter is not mended if you suppose the blind man's hearing to be so acute that he can register every stage of the struggle, and pretty clearly predict how it will end. He had better not meddle at all till his eyes are opened." This predicament of the blind man is probably not unfamiliar to every doctor, for at best human skill and knowledge often reach their limit before the disease does, but certainly every physician should be ready to exert himself to the full extent of his power to open his eyes as far as possible, to be as little blind and as seldom as may be. And as a blind man may be able to prevent a conflict which, once begun, he can not control, so the doctor may have sufficient knowledge to prevent disease which he can not heal. He may often be more certain of his position as a preventer than as a healer of sickness.
Although man stands at the head of creation, it does not necessarily follow that he has reached his highest possible position. It seems entirely reasonable to believe that a more thorough dissemination of sanitary knowledge and its more complete application in common, every-day life would develop a race of men longer-lived, more vigorous, happier, and better than any yet seen. It may be too late to do very much with this generation, but may there not be hope for the next, and the next after that? What might not a few, generations of right living, right feeling, right thinking men do for the race? Here, then, are opportunities within the grasp of the physician of the future such as await no one else—opportunities for useful, helpful work such as never before inspired the mind or stirred the heart of the professional student; such a privilege of effectually aiding in the advancement of the human race, of making it nobler and better.
Such opportunities well used must bring upon those to whom they are given a glorious benediction.
It should not escape the notice of the physician that this golden future will not inevitably be his to whom by right it belongs. By right, if he seizes it and holds it; but, if he does not, it must slip from him, as it should. Already many of the leaders in sanitary movements are not from among medical men. These, many of them, fail to appreciate their privilege; they do not see what is before them, but are so busily engaged in search of some pill or potion which may or which may not cure some disease, that they can not see the treasure which lies just within reach. The whole work of medicine is important, and the search after remedies should not be abandoned as useless, neither should it take the place of greater and more important labors. It is a noble thing to give time and strength to the discovery of means which may be used to heal disease or alleviate pain, but it is a far grander and nobler task to teach the people how to live so that disease and pain will not come upon them.
- An Address delivered at the opening of the Twenty-ninth Annual Course of Lectures in the Medical Department of the University of Vermont.