Popular Science Monthly/Volume 48/January 1896/New Outlooks in the Science and Art of Medicine

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I WANDERED last summer over that marvelous land of sunshine in our great Southwest where still fast dwindling groups of the real Americans cherish quaint customs, and linger among the superstitions of vanished centuries. And Fortune made me for a time a guest in a small tribe of these Indians, as yet almost untouched by the blighting finger of what to us is civilization.

I was drawn to them in this way: There came to our camp upon the plains, one evening, a woebegone dark fellow of this tribe, who with his squaw had wandered away from his comrades, seeking a quiet place to die. He was wan and feeble. A demon, he told us, had long since gained entrance to his body and had tortured him with pain and cold and fire. All the art of his tribal medicine men had failed to free him from the intruder, and a little while before, some spirit had begun to whisper to him in his sleep, he said, that he must go into the dark. All this was gathered from lip and gesture and pantomime as he lingered with us, loath to relinquish at the last the scant comfort of human companionship.

In the light of the lore which had been imparted to me many years ago by my medical teachers here at Yale, I reckoned him the victim of malaria; and shortly, in fact, quinine had cured him. The demon was exorcised, the spirit ceased to whisper, the sun was again his friend, and the winds began anew to breathe to him their wonted biddings to the chase. The grateful soul, now eager to be away, was urgent that I should visit his people, for he was fain to celebrate the facility of the white medicine man who could banish evil spirits without rattle, dance, or chant. And so I went. Eighty miles across the desert from any settlement, down at the bottom of a rock-walled chasm which leads into the Grand Canon of the Colorado, and whose sides tower sheer half a mile, these brown-painted folks have lived alone and almost forgotten since long before the Spanish pioneers came hither for God and gold some centuries ago.

At the time of my visit several persons in the tribe were ill, and a celebrated medicine man had been summoned from afar in council over the stricken ones. After long and repeated conferences, my dark medical brothers consented to lay aside cherished forms of professional etiquette, and permitted me to take a place in the grave circle which at midnight crouched about a small fire built in the open, near which lay, half naked, the group of patients. One of these was clearly the prey of consumption; one was shivering with malarial poisoning; one was a croupy child; one I judged to have partaken unwisely and too much of spoiled jerked meat; and one was the victim of old age. I have not time to picture for you, as I should like to do, the weird scene which was enacted there from midnight until dawn, night after night. A low rhythmic chant rising and falling to the time of a rattled gourd; slow passes of the hands over the prostrate bodies, which now and again were blown upon from the pursed lips of the painted ^sculapius, who now crouched crooning beside his charges, now danced furiously about them, while at frequent intervals wild yells from the attending circle woke hideous echoes from the cliffs. I will not dwell upon the sequels of this adventure, but remind you only that the conceptions of disease which these people foster, and the practices which they adopt to free the body from what is to them a definite possession by some evil thing, are essentially those which were prevalent ages ago, and whose significance we glean so toilsomely to-day out of the misty and broken records of the past.

I have lingered in story on the threshold of this address, because I wish to emphasize the fact that in this country and to-day in all countries of the world, for that matter a large proportion of mankind, consciously or unconsciously, personify disease or think of it as something foreign to the body, some definite or mysterious thing intrusive. From the painted red man of the plains, who associated his bodily ailments with demons, spirits of the dead, witchcraft, magic, evil possession, and angry gods, and hopes to banish these with shrieks and songs, it is indeed a far cry to the clean, clad, business or professional white man of the town, who more or less sheepishly confesses that he carries a horse-chestnut or a potato in his pocket to ward off rheumatism. But between the charm of the horse-chestnut and the chant of the savage lies a great body of ignorance and superstition, upon which quacks flourish mightily, and which can not be altogether ignored in any wide outlook to-day over the field of medical science and medical art.

In fact, the superstitious red man is much more reasonable and logical in his procedures for the cure of disease, considering the scope and character of his conceptions of its nature and the phase of civilization which he represents, than are large numbers of considerably evolved white folks who, in the midst of highly civilized and cultured communities, bow still at the altars of sanitary savagery, cherish a devotion to drugs almost pathetic, and utterly fail to grasp the significance of the new conceptions of disease which at last have made of medicine an exact science.

That which has especially contributed to the establishment of medicine on a firm and rational basis is the gradual centering of our thought and experiment upon definite and tangible structural features of the body, and the conviction that the physical nature of man is closely interlinked with that of lower forms of life.

In its primitive phases, medicine brought gods and men into close relationship and led constantly to religious conceptions. It was, in fact, not a science, but a religion. The early priests were physicians, the primal gods were gods of healing, and their temples were hospitals. As time passed, absorbing speculations, fantastic often, frequently grotesque, about the structure of the body and the nature of disease, won general belief and disappeared. Theories, systems, and schools came and went. Now mysticism and magic, now humors and philosophy, held sway. Quackeries and frauds flourished for their little hour, and vanished, as they always must. Finally, the body itself became the object of direct study, and the mysteries began to clear.

But it was a long time after it became reputable and legal to study the anatomy of the human body before the old physicians acquired a definite conception of it as an admirably grouped assemblage of tissues and organs. It took much longer for the development of accurate notions as to the functions and uses of

VOL. XLVIII. 26 the separate parts of the human frame. And it was not until the early decades of the present century that science was able to declare the ultimate element out of which all these varied parts are built to be a tiny particle of living matter which was called a cell.

Somebody has said of Turner that he was a man who thought in paint. The modern devotee to medicine, if he seriously thinks at all, must think in cells. Physicians used to think in symptoms, and it took them a great many years to learn that they must think also in cells and organs that is, with clear morphological conceptions if they would crystallize for use the knowledge which experience brought them.

Through the long processes of evolution, these cells have acquired peculiar forms, and adapted themselves to the performance of special functions. The great cell groups we call them liver, lung, brain, muscle, bone each doing its particular work, all act in harmony for the maintenance of the life and performance of the body as an independent being.

We do not yet understand, nor shall we soon, what that marvelous vivifying influence is which sets this self -built cellular mechanism at work, and keeps it going, as a rule, under favorable conditions until the shadows of threescore years and ten begin to deepen about the worn machine. Nor has all our gathered life lore led us far among the mysteries which cluster about the vague region in which the spiritual and the material meet and interfuse. But this we know, that all the things the body does, from its high borderland achievements in thought and memory down through the homely processes of nutrition and repair, are accomplished by these small life units in accordance with physical laws as definite and unvarying as are those which we trace in plant and earth and star.

Under a variety of adverse conditions the human body can still hold its own and secure for a time a certain degree of health, thanks to the adaptability to circumstances of its component cells. Thus, by the nice control of its ceaseless chemical processes, the body can maintain a nearly uniform degree of heat, no matter what the latitude or season. Starve the body, and its cells can feed for a while upon the stores which they have in times of plenty laid aside. They struggle long and faithfully against the manifold excesses which may be forced upon them. They fight with fashion, in one sex at least, for space within this none too roomy tabernacle, with business and with pleasure for a time to rest, with drugs and blighting drinks and unwholesome foods for release from poisons which it is not usually thought criminal to administer to one's self. They work as best they can without the wholesome air so frequently denied them. They resist with what force they can muster inherited weaknesses or taints. But after a time, when the conditions under which the cells live and work are definitely unfavorable, they may fail to maintain the standard. Their performances become faulty or feeble, or, with their structure, may largely change. If carried beyond a certain limit, these weakened or perverted functions and their attendant physical changes constitute the condition called disease.

In fact, science does not now permit us to forget that "the living body is a mechanism, the proper working of which we term health; its disturbance, disease; its stoppage, death." The happy condition known as health does not commonly draw attention to itself, and so has escaped personification; while the other conditions disease and death, strictly its analogues from the earliest times have been invested with such mysteries as among all people have led to misconception and to figurative speech.

I wish especially to emphasize the simplicity of the modern scientific conception of disease as a disturbed condition of a complex cellular mechanism, because it is largely due to a failure to comprehend this that the shadows of the middle ages actually still lie dark over certain of the popular conceptions of medicine, and seriously retard the speedy fruition of many of its new discoveries.

The practical ends which have been of necessity held in view by the devotees to medicine, the bald empiricism through which most of the therapeutic resources of our art were won, and the stubborn persistence of old and misty conceptions of disease have greatly hindered the realization of the fact that medicine is, after all, only one phase of the great science of life which we call biology, and that its varied themes must be pursued by the same methods and under the same strict safeguards against error in observation and in inference as are current among those who study science in its simpler aspects. It may make some practical difference that the particular animal to which the medical man devotes his time is highly complex, fosters a soul, has a future, and pays in cash (sometimes) the expert who can relieve it from discomfort or pain and prolong for a little now and then the cellular confederation. But if we do not constantly draw light from the common sources, we shall wander hopelessly in empiricism and fail at last. In truth, to strive for wide comprehension of the human frame without the constant aid of sister sciences and frequent reference to simpler forms and functions is but to build upon the surfaces.

Permit me now in a somewhat desultory fashion to glance with you at two or three phases of recent development in medicine. I have not wished to frame an exhaustive inventory of our gains, but rather to note such features as can be led to wider beneficence through forces which we may ourselves administer as we go about our usual tasks.

When we group diseases according to causation, we find that many are due to excesses excesses in food, in drink, in drugs, in exercise, in indolence, in work, in rest, in play. Sometimes the body labors under adverse influences which we do not understand. Sometimes the organism is handicapped from the start by inherited defects. Sometimes subtle poisons which the body itself forms are not properly disposed of, and the organism suffers.

In spite of the vast stores of experience with the human body in disease, clear down to the early part of the last decade, the nature and cause of some of the most common and fatal human maladies were practically unknown. I speak of the diseases which we call infectious. These were so widespread and so mysterious as to foster su]3erstition, and lead to the perpetuation of the earlier notions about angry gods, oft'ended Providence, judgments, warnings, witchcraft, and so forth, long after the legitimate presence of such developmental j^hases in human thought had passed away. Man had gone on making up inventories of his visible life neighbors in the world, had traced their pedigrees and relationships, had found how closely their evolution was bound to his own, and had got the systems pretty well completed, when his surprised attention was called to an inconceivably populous world of beings lying far beyond the reach of the unaided vision and closely woven into the chain of life. And shortly the so-called "germ theory" of disease had ripened into a wellgrounded body of positive knowledge, so far-reaching and significant that more than anything else it has seemed to dominate medical science for more than a decade, and has led to most beneficent practical results in the prevention and the cure of disease.

For a good while after attention had been called to the existence of microbes, most people thought of them many still do almost exclusively as inciters of disease. But this is a most narrow conception. The amount of material on the earth available for the temporary uses of living things is limited, and it is largely through the intervention of these lowly but active organisms that when once the material, which for a little while has come under the sway of the life forces, has fallen into death, it is rescued and worked over into available life stuff again. And so, chained over to the material, the cycle of life on the earth is maintained only through these swarming hordes which serve all animate things in serving their own necessities.

We can to-day trace their presence through geologic ages, sharing in the life of earlier times. We are but just beginning to realize their vast economic importance in agriculture, in the vineyard, the dairy, and the kitchen, in certain of the arts, in the normal processes of digestion, and in the maintenance in many ways of the salubrity of the earth and air and water.

The sooner we realize that the exercise of their disease-producing powers by the microbes as a class is only an incident in their largely beneficent careers, the sooner shall we arrive at a just comprehension of our newly discovered earth neighbors, upon whose ministrations we are dependent for the creation and the maintenance of conditions which make possible our being here at all.

The variety and complexity of the chemical transformations which microbes effect in the soil and in the water are but just becoming evident. But we already know that through the vast reaches of time which their life history covers the delicate work which they have to do has been intricately apportioned among them, and a most elaborate physiological division of labor adjusted. The struggle for existence among these lowly forms of life is so keen that they are almost always confined to their legitimate haunts and to their beneficent offices.

I need not refer in detail to the story of the discovery, one after another, of the bacteria which have been shown to cause fatal maladies. Tuberculosis, cholera, pneumonia, diphtheria, tetanus, anthrax, and more of the sinister brood have now yielded the secret of their causation.

At first the relationship of bacteria to the diseases which they were found to cause seemed quite simple. But as research went on it became clear that we were still only scanning the surface. It was shown that these intruding germs do not act chiefly by their mere presence as foreign bodies, but more usually or more fatefully by the elaboration of subtle poisons which permeate the body and destroy the cells or disturb their nice adjustment.

So the study of the products formed and set free in the life processes of these germs opened a new line of intricate and delicate chemical procedure. Think of the complexity of the processes which are induced in the body by the presence and action of these living organisms! We have, on the one hand, the body cells, each one, small as it is, a chemical factory, setting free unnumbered complex substances, some of which are to be used by the body as a whole, some to be resolved into other forms, some to be eliminated, since they are powerful poisons. To these multiform cell units of the body enter the germs, cells too, mostly plants, equally complex in their processes, also poison factories sometimes of most appalling energy and grown hardy through ages of strenuous battle for existence.

Great progress has been made in research upon the agencies which the body can bring into play to protect itself against these sinister intruders, and did time permit I should like to call your attention somewhat in detail to the mimic warfare which is maintained, often in extreme hazard, under conditions which belong especially to modern life.

There are still several tissues and organs about whose uses we are, in the main, ignorant; but there is much reason for the belief that several of these unknown mechanisms are largely useful in disposing of or rendering harmless numerous poisonous substances which in their complex metabolisms the varied body cells get free; and the recent revelations in the relationship which microbes bear to disease have made it seem probable that the agencies which the body has developed for its own protection against itself are the same agencies which it employs to protect itself against these small invaders.

We have learned of late that not infrequently more than one germ species may be at work in producing the cell disturbance which we call disease, and that an individual whose inherent protective mechanism promises a favorable outcome to the fight when one enemy alone is within the citadel, may speedily succumb upon the entrance of its allies.

It has been shown that the same germ, under varying conditions, can induce maladies hitherto thought to be different; so that the number of our unseen enemies in this silent realm may, as our outlook becomes more commanding, prove to be smaller than we have been led to think.

Several of the most fateful germs are constantly with us, especially in towns, but doing no harm, unless through some breach in the complex and curious line of the body's defenses they enter the sanctuary. Even then they are often harmless, as we have seen, except in an organism whose defensive mechanism is already weakened by excesses or disease.

The extreme rapidity with which these organisms multiply has made it possible to study experimentally, in the countless generations which come and pass within the range of a single experiment, the effect of environment upon their morphological and biological characters, and the existence of races and varieties within the limits of what we are pleased to call bacterial species has been well established.

It has been possible by changes of environment to so alter the metabolism of disease-producing germs that, though apparently growing as vigorously as ever, the poisons by which their evil effects on man are caused have lost their power. In fact, we now know several germs quite similar to those which are of most sinister import to man which, apparently, under what we call natural influences, have lost their power to harm. These are some of the lines of study with which bacteriology to-day is busy. But the greatest immediate practical benefit derived from the new knowledge of micro-organisms is the certainty with which some large groups of infectious disease can be controlled by private and public measures of sanitation.

Of course, in sanitation, as in other phases of morals, it is not as easy to do as to know what 'twere well to do. But it is safe to say that if we were ready in this country to follow such dictates of science in sanitary measures as are of known efficiency, we could secure their birthright of long life and health to a large proportion of that forty per cent of all the people who, as statistics show, are now destined to perish from preventable infectious maladies.

The means by which individuals and health boards may realize the possibilities for human weal so clearly indicated in the newly won lore of preventive medicine I need not here recount. They are easily enough learned as soon as the conviction of their importance has grown to a fixed purpose of action.

The scope of this address does not permit me to dwell upon the really wonderful degree of accuracy with which the educated and experienced physician of to-day can detect abnormal conditions in the varied cellular structures of the living body, nor upon the clear conception which he may acquire of morbid states and processes in situations physically inaccessible. He can recognize what groups of hidden cells are faltering in their work, are struggling under burdens, or in what way the co-ordinating mechanisms are failing in their tasks; and now in one way, now in another, and not most often with drugs, as so many think, can he tide the halting mechanism over its hour of stress. The cause of the disturbance may be removed, rest secured, pain assuaged, perverted function set right, and even for a time the aged, wornout mechanism encouraged to prolong its task. And if the physician can not so frequently as we would wish guide to the happiest issue the healing forces over which the human frame has gained control, it is certain that, other things being equal, his success is assured just in proportion to his accurate practical knowledge of the delicate mechanism which he is seeking to repair, and his comprehension of the nature of the life forces which he must in the right way and at the right moment aid, and with which he must as certainly not unwisely interfere.

In these hurried glimpses of only a limited phase of medicine, it is most significant that there is no talk of humors and auras and vital spirits, nor of illusive and intangible fancies such as for centuries held sway in fields once ruled by demons and angry gods, but of definite things which we can see and handle and measure. Herein, to my thinking, lies the heart of our achievement and the brightest promise for the future. But while our science and our art are now steadily growing in precision and usefulness, our practical accomplisliments are greatly limited, because general enlightenment regarding the things of the body has not kept pace with the acquisitions of science.

Our new outlooks in preventive medicine have made it plain, as I have said, that a very wide curtailment of suffering and a large saving of human life are possible if only the people can have an elementary knowledge of the human body and of such simple principles of hygiene and sanitation that under the increasingly complex conditions of modern life they may be able to guard against common forms of infection and against unwholesome modes of life, which not only invite infection, but many other forms of ill.

It seems to me that here the schools and the colleges have high responsibilities, and of these I wish briefly to speak.

The conviction has for some time been current that the children should be taught something about the structure and working of the human frame, and in this way already much has been achieved. Of the importance of this sort of knowledge no special demonstration is needed to-day. But in many of the public schools in this land the instruction in physiology and hygiene has been of late largely subordinated, if not actually falsified, to the interests of what some are pleased to call temperance; meaning thereby the avoidance of alcohol and tobacco, lest horrible and frequently impossible things should happen to the liver or the brain.

But I think that the distortion of truth is not liable to lead at last, no matter how worthy the motive, to the ends for which the anti-alcoholic and anti-nicotinal physiologies and hygienes of our schools have been devised. It seems to me certain that a great deal of the future physical and mental well-being of our people depends upon the acquirement early in life of absolutely accurate, though it be rudimentary, knowledge of this complex and sensitive bodily mechanism; and that the self-control and self-respect which such knowledge fosters will in the long run do more than vague fear of bodily ill to promote a temperance much more comprehensive and beneficent than that which centers itself in the avoidance of alcohol and tobacco, bad as the misuse of these may be. It is to be hoped that mistaken zeal in this direction may not long prevail to the physical and moral detriment of the children.

Many of our institutions for higher education now recognize the value of a knowledge of the body, and of the physical conditions under which man can best secure the highest usefulness and enjoyment. But I do not think that as yet this subject has received attention at all commensurate with its vital bearing upon the well-being spiritual as well as physical of those whom the universities equip. So long as a knowledge of the human frame was looked at from the standpoint of the dispenser of mysterious drugs to a mysterious organism for the purpose of expelling mysterious foes; so long as the body was regarded chiefly as a more or less disreputable tabernacle for the temporary uses of the soul; so long as its harmonious and significant relationship to other forms of being lay largely beyond our ken; so long, I say, as all these conditions prevailed, accurate knowledge of the body and the factors necessary to its physical well-being did not command attention in the higher educational outlooks.

The equipment which I urge is in no sense medical, nor is it such as encourages the fancy to linger upon trivial ailments or inspires the dread of disease. For it should be remembered that the fundamental facts of anatomy, physiology, hygiene, and sanitation do not belong particularly to medicine, as is too often hastily assumed. This knowledge is indeed especially useful to the physician, and upon it he builds up into the domain of medicine. But it is a part of the common stock of world lore. And I do not think that there are any forms of provisional knowledge among those which candidates for admission to the colleges are required to possess more important than this.

Nor can I regard any schedule for the higher education, no matter what the calling to which it is initiatory, as adequately comprehensive which does not embrace definite and well-balanced instruction in the more advanced knowledge of the human body, its relationship to other forms of being, and the means through which it best can serve those larger purposes of life which the university inspires. One often marvels at the pitiful ignorance of the body and of the simplest principles of healthy living common among learned and cultured men and women to-day. Ashamed not to know the origin of a word, or to fail in the comprehension of a literary allusion, masters in theology, wise in the law, keen in business, versatile and brilliant in society, they are prone to court disaster in senseless modes of life, and fall easy victims to charlatans and unscrupulous drug venders an association which they share with the illiterate and uncultured in a fashion highly democratic, and which suggests the survival of traits less incongruous and much more picturesque in the North American Indian.

Our new outlooks in medicine have not been won without toil and sacrifice on the part of its devotees, and these will still be necessary. But it is evident that in the medical colleges there must now be fuller endowment of research and more adequate provision for instruction, not only in the traditional themes of undergraduate study, so largely expanded, but also in recently developed disciplines.

The clear appreciation of the close relationship of medicine to other phases of biology; the newly recognized importance of practical familiarity with things themselves, rather than with the impressions which another has gathered and more or less lucidly imparts; the patient training of the hand and eye and ear to catch minutest variations in surface and color and shape and sound all these requirements of modern medical instruction involve pecuniary supx3ort far beyond that which was formerly suflBcient.

As was to be expected, the necessity for improvement in the medical curriculum and the urgency of the requirements of research have been recognized at this university in the revision and expansion of its medical course. And it is to be hoped that the appeal for endowment of the medical school here at Yale, made in the President's last report, may not go unheeded by those who are now for a little while the custodians of wealth, and in whose power it is to bring into play facilities for instruction and capacities for research so full in the promise of immediate practical utility.

What, now, is the attitude of the physician, in the light of the broader and more exact science which is to-day at his disposal? It may be at once conceded that his physical presence has mainly lost its old-time picturesqueness.

It is inevitable that as soon as he laid aside the mysteries and fictions and superstitions with which erstwhile he was wont to invest his calling, was obliged to abandon charms and auguries and secret remedies, and could no longer safely summon to his aid the occult forces with which outgrown fantasies invested plant and mineral and pregnant aspects of the stars, and was forced to confess that in dealing with his charges he was even, as other devotees to other sciences are, simply a student of common things with the simple resources of actual knowledge and common sense it was under these conditions, I say, inevitable that his claims to confidence must more definitely rest upon his sound learning, his obvious skill, his actual experience.

A large part of the late surviving professional mannerism and dictatorial assumption has also passed away, and the doctor of to-day is a man of the world, the friend as well as the expert.

It is a very wide-eyed generation which is coming on the scene, and not prone to invest with unnecessary ceremonial or mystery the dealings of its professional advisers with its ailments. Many laymen know as well as we do that the administration of drugs in their hour of stress is but an adjunct to the often more needful and more potent guidance in diet, in regimen, and in the varied general measure by whicb. the stricken organism may be nursed back to healtb.

And if we mumble and shift as we face legitimate inquiry as to the nature of disease and of remedial measures, and strive to foster the old conception of the body's hidden mechanisms as of a "strange internal kingdom of which we are the hapless and helpless monarchs," we surely can not justly protest if the baffled inquirer turn to the charlatan.

While in many cases the patient is so ignorant, so heedless, so indifferent, so little in control of his mental outfit, that the simple dictum of the doctor may convey all that is wise, it is still, I think, true that usually a clear and simple explanation of his condition and an enlistment of his intelligence, or that of his friends, in the nature of his malady and the measures proposed for its removal, not only often contribute to success, but also, on the ipart of the physician, are more dignified and more humane.

But, beyond this phase of helpfulness, the physician has the largest opportunity in his intimate dealings with his charges to so counsel and instruct that, especially in the routine of household life, the fundamental principles of healthy living may be understood and followed.

I am aware that to many physicians this is now the accustomed way; but it might, I think, wisely be the way more often trod.

Again, the practitioner of medicine has facilities for fruitful research to-day, however simple or obscure the field of his activity, such as no earlier time has realized because our problems are more precise, our methods more exact, and opportunity for interchange of thought abundant.

There is, indeed, no better example of the scientific method of research than the performances, physical and mental, of the wellequipped physician as he stands in the presence of this delicate mechanism faltering in its tasks. He summons his facts by story, by test, by observation; frames from them, in the light of all the lore which he can muster, a clear conception, or a theory if you will, of the cause and nature of the disturbance; and then, by all the varied agencies at his command, assumes the role of Nature's helper in the promotion of recovery.

There is nothing which the worker in the laboratory can do with his tubes and balances more strictly scientific than the work which engages the practitioner in his daily rounds. For it is the method, not the tools or place or subject of our tasks, which makes them scientific or unscientific. It is just as easy to be unscientific in the laboratory as at the bedside, and in either place it is easy to lose sight of science in the detail of mechanical routine. But beyond all that which the physician can accomplish as the friend and expert adviser of the sick in whom, first of all, his allegiance centers, as the student of all things which promise help in his fight against disease, as the friendly teacher ever mindful that prevention is better than cure, and as one who toils for Science for her sake alone beyond all these high offices there is yet another upon whose duties he must now more seriously enter, if he would hope to realize all that which our new outlooks promise. I speak of the duties of citizenship.

Municipal and State health organizations have accomplished much of late in the protection of the people against disease. But the humiliating confession must be made that in many measures of public sanitation in this country we are far behind the requirements of science. This is not, as a rule, because our health officers do not know what to do or how to do. It is not usually because they are indifferent or negligent. But in many cases the pitiful sacrifice of life and the inexpressible suffering and loss which preventable disease involves are due to legislative indifference or folly.

I am aware that there are many exceptions, but I think that I am not mistaken when I say that among the measures vital to the public welfare over which our legislators. State and Federal alike, wrangle and bicker and deal when these are not treated with indifference and contempt, as not contributory to the profit or to the disgraceful notoriety of the hour there are none which more often fail of intelligent consideration than those which concern the public health.

But laymen in public office can not be regarded alone at fault if they be not wisely directed; and physicians are not, I think, as keenly alive in this way as they should be to their responsibilities as citizens. They know what ought to be done in the larger public way to render the new knowledge in sanitation and the control of disease available, and yet do not individually or as a guild bring their expert knowledge strongly to bear as the intelligent citizen always can, if he be right and enough in earnest.

There is little doubt that almost any legislative measure which the medical profession unites and persists in urging as essential to the maintenance of the public health can be speedily secured.

I know that there is a general feeling among physicians of the better sort that conspicuous interest in public affairs may be misconstrued and looked upon as in some sort a means of professional advertisement. And one can not choose but appreciate and admire the sensitiveness and high sense of honor of which this sentiment is born. But, after all, there are greater misfortunes in life than being misunderstood, and I think that the fine feeling which leads the physician so often to waive the privileges of social and public life in the interest of what he conceives to be professional ethics is capable of a richer fruitage yet, in the defiance of misconstruction, when impelled to whatever performance of public duty he can justify to himself.

While the penalties of ignorance in things sanitary and hygienic are growing more severe as our communal life becomes more complex and crowded, there are, as we have seen, a good many ways in which the lessons of modern sanitation can be learned. Some of these lessons may wisely, as I think, be woven into the educational equipment of the young. They may be acquired in later life from books. Many may be assimilated under the kindly offices of the physician. Much is taught by such public measures as health boards may enforce. But, learned these lessons must be sooner or later, and learned they are too often now at the bedside and the grave.

Physicians know well enough that a stringent system of dairy inspection should be at once and widely enforced, and it is really for them more than for any other class of citizens to say how many more object lessons will be necessary like those recently enforced at Montclair, at Waterbury, and at Stamford, before all such caterers shall be compelled to conform to the rules of sanitary decency. The prevention of pollution of water supplies, the compelling of reasonable cleanliness in public vehicles for human transportation by land and by sea, the enforcement of precautions against the spread of disease in public hostelries and places of assembly, the organization of a national health bureau these are all tasks which must speedily be undertaken, and they may be led to rich accomplishment if the physician will but hold more clearly in his consciousness his primal duty as a citizen.

In all that which I have urged about the more precise physical and, I might almost say, mechanical nature of the professional duties which in the new light the physician is called upon to assume, I have purposely left largely out of sight his more intimate personal relationships to those to whom he ministers. And yet, lest one should fear that in our eager search for light we overlook the man in the machine, I should like to assure the timid that all that which always has and ever will dignify and ennoble his calling, as one who is strong serving the weak, remains unchanged in the physician, and is potent or feeble, not in ratio to his scientific knowledge, but as he is more or less honest, keen of insight, high of purpose, sympathetic; and finds its highest fruition joined to good judgment and self-reliance, and to whatever confidence- winning and hope-inspiring qualities he can command.

It is not easy to estimate accurately the scope and value of contemporary achievement. But as I look over the field of medicine, with all its varying lights and shades, it seems to me that the tilings which are most deeply significant in these closing years of the century are not the newly gained skill in diagnosis, not the marvelous strides which surgery has made, beneficent as these may be, not the more exact and purposeful and moderate use of drugs, not the insight which has been gained regarding the complex nature of the nervous system, nor even in the high achievements, too numerous and varied to be even mentioned here, which the new science of bacteriology has made possible.

Beyond all these accomplishments, notable enough though they be for any age, the things which more than all else, it seems to me, will signalize this time, are that we have now definitely freed medicine, in all its borders, from the thralldom of mystery and superstition, have finally and clearly recognized that its problems are the problems of biology, and are to be solved only by such patient research and guarded inference as all science has learned to trust; that the doctor is in command of no mysterious forces, and that the only chance for the full and speedy fruition of our hope in the prevention of disease lies in general education, and in the enlistment of the interests of the people, of whom the medical profession should be the teacher and the guide.

Of course, the shadows here and there will linger on; of course, one and another for some time to come will still invest his calling with the puerile mysteries which were fostered in ignorance, and which should have been put aside with the scarlet cloak and the wig and the ponderous walking stick. Of course, so long as the people are largely ignorant of elementary facts regarding the human frame, quacks will flourish and more or less well-meaning advocates will be found of water, of electricity, of faith, of exorcism, of infinitesimal dosage, and of every sort of named and unnamed folly, as panaceas and as substitutes for science. But, after all, when medicine is once placed where it belongs, close to its sister disciplines, from which it gathers light and in its turn inspires, the shadows are certain soon to fade and the truth to prevail.

You will observe, ladies and gentlemen, that the current of my thought has led again and again to the outlooks which command the field of preventive medicine. This is not only because here the new light shines brightest, and gives clearest glimpses of definite achievement, but also because upon this field success is possible only if we can secure general and earnest co-operation in the spread of the new ideals of cleanliness.

In truth, the exactions of our modern sanitary codes, so far as they affect the performances of the individual and the routine of the household, are neither complex nor burdensome; and a very moderate amount of care, if happily joined to informed intelligence, will suffice, under almost all conditions, for the maintenance of a safe regime. You will, I hope, forgive me for casting the shadow of disease over the festival spirit of this hour. But, after all, our lasting enjoyment is most frequently secured by such physical well-being as these new outlooks in medicine promise to cherish.

And so, gentlemen of the graduating class, at last, to the lifelong study of this science which looks out upon so many pathways toward the light, and to the practice of our art, whose aims are ever closely linked to the high realities of life, it is now my privilege, on behalf of our guild, and in the name of the Faculty of this ancient and honored college of medicine, to bid you a cordial welcome.

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  1. An address before the graduating class of the Yale Medical School at Commencement, on June 25, 1895.