THE FUTURE OF MEDICINE.*
IN this volume the author once more puts forward his views on the progress of medicine, explains the reasons for the faith
that is in him, and demonstrates, chiefly from his own work on disorders of the heart, how the investigation of disease should be conducted. The views expressed are those already criticized in an article on " National Health " published in the Spectator of March 1st, 1919 ; but while relinquishing none of his opinions, the author adopts a more conciliatory tone than he did in the address published in the Dominion Medical Monthly, or rather the elaboration of the theme appears to modify the aggressiveness of the article, and one lays aside the book with a feeling of great respect and admiration for this great and honest physician.
The Future of Medicine is a plea for the simplification of medicine, a reaction from the over-elaboration of " labors- toryiam "—i.e., the instrumental and other laboratory aids to diagnosis. Not that Sir James denies the usefulness of these methods in research work, but he maintains that, while in some conditions it may be necessary even in ordinary clinical work to use elaborate instruments, it should be the constant aim of the medical inan to learn how to discard such instrumental aids, and claims that he is now able to do so in much of his clinical work on diseases of the heart•. What the author is so strongly opposed to are the laboratory ideals outlined in the syllabus for students recommended by the Professor of Clinical Medicine at the world-famous Johns Hopkins University, Baltimore, reprinted in this book, and occupying more than four closely printed pages. It is a portentous document, burdened with such terms as teleoroentgenography, ortho- diagraphy, and phonocardiography. Whatever view may be held as to the need of simplifying medicine, that benefit would result from simplifying medical terminology can hardly be questioned.
Now all these instruments and methods have their special uses, and by means of them valuable advances in our knowledge and coneeptioa of disease processes have been made. This the author concedes, but he maintains that they only bring informe- r ion when disease has produced tissue change, and when therefore real cure is impossible, or at least very difficult. Moreover, islianco on such instrumental aids tends to a neglect of the observation of symptoms, on an accurate assessment of which trustworthy prognosis and truly scientific treatment can alone be based. It would indeed appear to be a truism that before a student can be expected to make proper use of these instru- ments he must• first be taught to develop his powers of observation aided only by his senses of sight, hearing, and touch ; and we believe it to be, unfortunately, true that the student of to-day itiishes his medical course with these powers far less developed than did the student of twenty years ago. For example, he is inclined in a case of a possibly fractured bone to submit the patient to an X-ray examination without spending much time aver his own examination of the condition. However, if he be observant, having obtained the radiologist's opinion, he is in a better position to recognize the symptoms of a fracture as distinct from, say, a sprain, whereas he often regarded certain signs as indicative of a severe sprain, which the radiologist has since shown to be due to fracture.
Still, this question of over-reliance on instrumental aids is not the gravamen of the author's charge against the medical pro- fession, which is that the study of early, often entirely subjective, sensations is almost entirely neglected by it, attention being focussed on the later and grosser symptoms. Sir James has to admit that, except in the case of heart disease, his study of symptoms has not brought him very far, attributing some of the blame for such shortcomings to the faulty nature of the teaching of his day in his medical school, at a time when, by the way, instrumental aids to diagnosis and treatment were very limited, but when the same, if not so highly developed, system of making hospital appointments was adhered to.
And now we have come to that part of the book which is most controversial and most likely to anger some members of the medical profession—the part in which the writer criticizes the appointments to the staffs of teaching hospitals, and inci- dentally runs atilt at the Royal College of Physicians, any one not a member of this august body being disqualified from • The l'atNre of Medieine. By Sir James Mackenzie, F.R.S., M.D., FIZ.C.P., LL.D. (Ab. d: Ed.), F.R.C.P.L. (lion.). London : Hodder and Stoughton. 18s. Od. net:4 obtaining an appointment as a physician in a teaching hospital :-
" A young aspirant to such a post must follow certain lines which custom prescribes. He can exclude himself from having any personal contact with patients by spending his time in a laboratory, undertaking what is called ' research,' and this is the surest way of attaining his object. He may spend his time in any form of academic life, but one method he must not pursue—be must not attempt to qualify himself efficiently for such a post by the experience of general practice."
In any case Sir James does not consider that hospital practice as at present conducted gives any opportunity for the thorough study of disease. If this is true, and there seems much to be said for this contention, it is a great pity, for among hospital physicians are to be found many of the brightest intellects in the profession, even if they have not, as a few, and only a few, of them suppose, a monopoly of intellect. The author's sug- gestion is that in every medical school there should be one or more teachers who have been in general practice for ten or twenty years.
It is obvious that the questions discussed in this book are of the greatest interest both to the medical profession and to the public. So important are they that hasty generalizations and conclusions must at all costa be avoided. While it may be conceded that the study of symptoms, especially early symptoms, has been sadly neglected in the medical schools, and that there has been coincidently a tendency to exalt " laboratory-ism," yet in general practice the reverse holds true. Since, however, the text-books are written by hospital physicians and the teaching is imparted by them, the general practitioner, if Sir James's contentions arc correct, will start ill-equipped for the work of observation he has to undertake. All the same, one cannot help feeling that the disadvantage of the present system of teaching in the medical schools is exaggerated by the writer, and that, were the attempt made so to alter it as to meet the demands of a man of so keen an intellect as Sir James Mac- kenzie, a few giants might be reared, but that the work of the average man would suffer. Finally, while agreeing that sympto- matic treatment is often the best treatment, and that diseases are not definite entities, but are varying responses to injurious influences, varying even when the initial cause is the same, we feel strongly that the study of symptoms should not lead to neglect of the search for causes, on which alone really satisfactory treatment can be based.
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