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 By Austin Flii/t
 
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 UNIVERSITY OF CALIFORNIA, SAN DIEGO 
 LA JOLLA, CALIFORNIA 
 
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 W 9 F623m 1886 
 UNIVERSITY OF CALIFORNIA, SAN DIEGO B 
 
 3 1822 01099 2097 
 
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 MEDICINE OF THE FUTURE 
 
 AN ADDRESS PREPARED FOR THE ANNUAL 
 
 MEETING OF THE BRITISH MEDICAL 
 
 ASSOCIA TION IN 1886 
 
 BY 
 
 AUSTIN FLINT (Senior), M. D., LL. D. 
 
 NEW YORK 
 D. APPLETON AND COMPANY 
 
 I, 3, AND 5 BOND STREET 
 1886
 
 Copyright, 1886, 
 By D. APPLETON AND COMPANY.
 
 The late Dr. A ustin Flint tvas appointed to read 
 
 the address on Medicine before the British Medical 
 
 Association at its meeting in 1886. The manuscript 
 
 was found among his papers and the address is 
 
 printed precisely as it zvas written. The proof was 
 
 reverently read by his son, zvho dedicates this, his 
 
 fathers last literary work, to the profession he so 
 
 loved and adorned. 
 
 AUSTIN FLINT. 
 
 April 24, 1SS6.
 
 MEDICINE OF THE FUTURE. 
 
 The meditations of a medical practitioner whose 
 retrospections extend over half a century may natu- 
 rally be expected to revert to the past. To re- 
 view the progress of medicine for fifty years, to 
 make comparisons of the beginning and the end of 
 that period, to revive the enthusiasm of by-gone 
 days — these are among the resources of those who 
 may be called medical semi-centenarians. In the 
 ability to look backward through so long a period, 
 is to be found some compensation for deprivations 
 incident to the passage of one's life beyond youth 
 and middle age. Retrospection has uses apart 
 from this compensatory gratification ; but, if too 
 absorbing, it impairs appreciation of the present 
 and faith in the future. To look forward, as well 
 as backward, is both interesting and useful. If our 
 retrospections extend over half a century, it is 
 worth while to inquire, How will the present ap- 
 pear in a retrospective view at the end of the next
 
 6 MEDICINE OF THE FUTURE. 
 
 fifty years ? In the spirit of this inquiry, I shall sub- 
 mit some thoughts on medicine of the future. 
 
 I assume that medicine, as it is to-day, will 
 not remain stationary. In everything relating to 
 human knowledge, anticipations have no basis 
 other than experience. The past history of medi- 
 cine shows a law of progress ; hence, medicine will 
 continue to advance. I shall view this conclusion, 
 however, from another and a higher standpoint. If 
 we believe in an overruling Creator and Governor 
 of the universe, everything, however great or how- 
 ever small, must be in accordance with a divinely 
 ordered plan. Diseases doubtless have their uses, 
 some of which are apparent to human comprehen- 
 sion. The prevention and the successful manage- 
 ment of diseases also enter into providential design. 
 The past gives an assurance of progressively in- 
 creasing security of human life from diseases. The 
 progress of medicine belongs, therefore, in the 
 order of Providence. 
 
 Past experience shows that medicine advances 
 by means of discoveries and improvements which 
 mark epochs in its history. Immediately preced- 
 ing the beginning of the last half-century, follow- 
 ing the discovery of vaccination, by Jenner, and the 
 developments in anatomy, physiology, and pathol- 
 ogy, by the researches of John Hunter, were the
 
 MEDICINE OF THE FUTURE. 7 
 
 discovery of auscultation by Laennec, the inaugura- 
 tion of renal pathology by Richard Bright, the crea- 
 tion of general anatomy by Bichat, and the advance- 
 ment in knowledge of the nervous system by the 
 experiments of Magendie and Charles Bell. These 
 were epochs occurring in quick succession. The 
 epochs within the last half-century have been as 
 many, as important, and as rapid as during the pre- 
 vious fifty years. They whose retrospections em- 
 brace this period of time can recall the discovery 
 of the reflex system of nerves, and of the separate 
 functions of different portions of the spinal cord ; 
 the study of diseases after the numerical method ; 
 the recognition of the self-limitation of certain dis- 
 eases and knowledge of their natural history ; the 
 creation of histology, by means of the microscope ; 
 the localization of certain of the cerebral functions ; 
 the employment of anaesthetics and their applica- 
 tions in medicine as well as in surgery and ob- 
 stetrics; the clinical introduction of the ophthal- 
 moscope and the laryngoscope ; the clinical use 
 of the thermometer; and, as a crowning epoch, 
 the more recent revelations respecting the bacterial 
 origin of diseases. Now, suppose that whoever may 
 be honored by an invitation to read an address 
 on medicine at the annual meeting of the British 
 Medical Association in the year 1936 should select
 
 8 MEDICINE OF THE FUTURE. 
 
 as his theme the history of medicine for the pre- 
 ceding half-century, is it to be doubted that the 
 epochs belonging to this history will be found to 
 be not less in number and in importance than those 
 which signalized medical progress during the first 
 half of the century ending at that date ? Does not 
 the history of medicine show a steady acceleration 
 in progress, so that, judging by the past, these next 
 fifty years will be richer in epochs than the pre- 
 vious half-century ? * 
 
 Has our knowledge of the organs, tissues, and 
 chemical constituents of the body reached its limi- 
 tations? About half a century ago, Horner, of 
 Philadelphia, described a lachrymal muscle, which 
 bears his name, measuring three lines in breadth 
 and six lines in length. At that time this little 
 muscle seemed the only thing left for discovery 
 in macroscopical anatomy. But soon afterward, a 
 new continent in this department of medicine was 
 discovered, and the question now is, How much 
 further can future exploration in microscopical 
 
 * Sir James Paget, in his inaugural address at the opening of the 
 International Medical Congress in 1881, expressed his belief that the 
 progress of science " in the last fifty years was twice as great as that 
 in the previous fifty," and that " the rate of progress should constantly 
 increase." If the latter belief be in accordance with the order of 
 Providence, how interesting will be the retrospections of half a century 
 in 1936 !
 
 MEDICINE OF THE FUTURE. g 
 
 anatomy be extended ? To particularize the epochs 
 to take place in the future would be equivalent to 
 making them ; but conjecture respecting the means 
 by which they are to be made is admissible. It is 
 probable that the construction of the microscope 
 admits of continued improvements. The illumina- 
 tion of microscopical objects may be increased. 
 The practical applications of the spectroscope may 
 be enlarged. The developments in optics may 
 furnish new methods of observation. The process 
 of staining, which has recently done so much for 
 pathology, may be extended and applied to the 
 study of the normal as well as morbid compo- 
 nents of the body. It is a fact, significant as re- 
 gards the future, that the use of dyes has brought 
 into the range of vision objects which, without 
 their use, the microscope fails to make visible. 
 
 Analytical chemistry carries investigation be- 
 yond the limits of microscopical observation. The 
 latter, at the present moment, both in pathology 
 and physiology, seems to promise most ; but is it 
 not a rational anticipation to look for future results 
 from chemical analysis of the components of the 
 body, in health and disease, which in brilliancy and 
 practical utility may surpass those of the labors 
 in this field of investigation during the past half- 
 century ? The medical semi-centenarian can recall
 
 IO MEDICINE OF THE FUTURE. 
 
 the enthusiasm aroused by the labors of Liebig. 
 Histology is now in the ascendant, but it is safe 
 to predict that, before the lapse of another half- 
 century, there will be another era in organic 
 chemistry, and that light will penetrate dark re- 
 cesses which histology can not reach. Tracing to 
 protoplasmic cells physiological and pathological 
 processes brings us in close proximity to these pro- 
 cesses, but they are not thereby elucidated. His- 
 tology may disclose the agents, but it leaves us in 
 the dark as regards the agencies. How is it that 
 secretions, excretions, nutrition, growth, and cer- 
 tain morbid products are brought about? This 
 question can not be answered with our existing 
 knowledge, and the answer must come from or- 
 ganic chemistry. The supreme objects of study in 
 pathology at the present time are the discovery of 
 micro-organisms and their natural history. But 
 these agents, it is probable, are pathogenetic, not 
 directly, but indirectly, by means of the toxical 
 products of their activity. What are these prod- 
 ucts, and how do they give rise to the phenomena 
 of disease ? We may ask the same question of cer- 
 tain of the poisons introduced from without the 
 body. How is it that fractional quantities of mor- 
 phia, hyoscyamin, strychnia, aconitia, atropia, and 
 other alkaloids, produce their lethal effects? It
 
 MEDICINE OF THE FUTURE. \ \ 
 
 conveys no adequate information to say that they 
 act upon the nervous system. This is merely the 
 statement of a fact, not an explanation. For the 
 latter, we must look to the organic chemistry of 
 the future. 
 
 The progress of medicine, so far as it depends 
 on observation, has been effected especially by the 
 sense of sight. The sense of hearing, it is true, has 
 contributed most important information, especially 
 respecting the organs within the chest. It is need- 
 less to refer to the knowledge obtained bv means 
 of auscultation and percussion of the lungs and 
 heart. A large share of this knowledge has been 
 obtained within the last half-century. It is need- 
 less, also, to refer to the marvelous developments, 
 within the last few years, of knowledge respecting 
 the transmission of sounds outside of the body, as 
 exemplified by the telegraph, the telephone, the 
 microphone, and the phonograph. These develop- 
 ments have not as yet added much to our knowl- 
 edge of the normal and abnormal actions taking 
 place within the body. Much is to be expected 
 from this source in the future. It seems to me cer- 
 tain that the principle of the telephone will, by-and- 
 by, be applied to intra-thoracic respiratory and 
 heart-sounds, so that they will be transmitted to 
 the ear with more distinctness than they now
 
 12 MEDICINE OF THE FUTURE. 
 
 are by the binaural stethoscope. The healthy and 
 morbid sounds will then be so easily observed as 
 to render the physical diagnosis of pulmonary af- 
 fections in all cases a very simple problem. More 
 than this, the clinical teacher may be able to dem- 
 onstrate auscultatory signs to a class of medical 
 students comfortably seated in the lecture-room or 
 hospital amphitheatre. The same is to be said of 
 auscultation of the heart. The cardiac murmurs 
 and the sound produced by each of the valves of 
 the heart separately, will be observed more readily 
 and satisfactorily than with our present means of 
 observation. I will go further, and say that intra- 
 thoracic sounds may be transmitted from the pa- 
 tient to the physician, no matter how distant may 
 be the one from the other. Again, and still fur- 
 ther, the sounds from the chest of a patient may 
 be phonographically registered, transported never 
 so far, and made available after an indefinite period. 
 All these results would not be more wonderful 
 than the invention of the telegraph, the telephone, 
 the microphone, and the phonograph, all of which 
 have been devised within the last half-century. 
 
 I may mention an incident, an account of which 
 I recently read in a newspaper, illustrative of a 
 practical use of the telephone in diagnosis. A tele- 
 phonic communication existed between the house
 
 MEDICINE OF THE FUTURE. 13 
 
 of a physician and the distant residence of a pa- 
 tient. The physician was summoned to visit a 
 child 'in the house of the patient in the night-time. 
 The physician naturally asked, " What is the mat- 
 ter ? " The answer was that a child had croup. 
 Said the physician, " Bring the child close to the 
 telephone that I may listen to the cough." This 
 was done. The cough was heard, and the physi- 
 cian telephoned his opinion and instructions, with- 
 out the necessity of making a night-visit. A de- 
 scription of the symptoms in certain cases, transmit- 
 ted by means of the telephone, may not infrequently 
 spare both the physician and the patient the incon- 
 venience of a journey either in the night or day 
 time. How far it may be for the interest of the 
 physician to make use of the telephone in this way, 
 depends on circumstances, the consideration of 
 which is not especially suited to this occasion. 
 
 In 1705, Robert Hook, who, as we are told, 
 " was for many years a prime mover in English 
 science — mathematician, physicist, chemist, engi- 
 neer, microscopist, physiologist, virtuoso, and city 
 surveyor — a man of almost unbounded fertility and 
 vast energy," uttered this prophetic exclamation : 
 " Who knows but that one may discover the works 
 performed in the several offices and shops of a man's 
 body by the sounds they make, and thereby dis-
 
 H 
 
 MEDICINE OF THE FUTURE. 
 
 cover what instrument or engine is out of order ! " * 
 Were Hook now living - , he might claim that his 
 prophecy has been fulfilled by the developments 
 in auscultation of the respiratory organs and the 
 heart. Moreover, auscultation has developed signs 
 in addition to those relating to the voice, the respi- 
 ration, and cardiac sounds. Fifty years ago, Fisher, 
 of Boston, found, on applying the stethoscope over 
 the fontanelles in infants, a bellows-murmur in cases 
 of cerebral diseases. Another of my countrymen, 
 Hooker, of New Haven, studied the intestinal bor- 
 borygmi in cases of colic. Murmurs in the arteries 
 and veins, and in the several varieties of aneu- 
 risms, as is well known, afford important informa- 
 tion. Pregnancy and the prospect of twins may be 
 ascertained by listening to the sounds of the foetal 
 heart. A collection of gall-stones is sometimes 
 made known by the noise they make, and hydatids 
 have been recognized by a musical tone. But the 
 fulfillment of Hook's prophecy is not yet complete. 
 At the present day, we may say, Who knows but 
 that, with improvements in instruments for the con- 
 duction and intensification of sounds, one may study 
 normal and abnormal conditions of the circulation in 
 all the internal organs of the body, " by the sounds 
 
 * " Inaugural Address," by Dr. Michael Foster, President of the 
 Section on Physiology, at the International Medical Congress of 1881.
 
 MEDICINE OF THE FUTURE. 15 
 
 they make " in the processes of secretion and excre- 
 tion, of nutrition and of morbid growths ? It can 
 hardly seem an extravagance to predict, then, of the 
 future developments of auscultation to one who has 
 listened, with the aid of the microphone, to the foot- 
 steps of a fly. 
 
 A half-century ago, the profession had acquired 
 but imperfect knowledge of the natural history of 
 diseases — that is, the history of diseases pursuing 
 their course unaffected by active measures of treat- 
 ment. The importance of this knowledge was not 
 fully appreciated. Diseases which we now know 
 to be self-limited in duration, and to tend intrinsical- 
 ly to recovery, were treated as if their continuance 
 were indefinite and their course interminable, irre- 
 spective of active therapeutic measures. The in- 
 fluence on therapeutics of the knowledge of the 
 natural history of diseases, acquired within the last 
 fifty years, has been great. It is evident that this 
 knowledge is the true point of departure for esti- 
 mating the effect of treatment, and that without 
 this knowledge the conclusions derived from clini- 
 cal experience must often be erroneous. There is 
 still room for the increase of this knowledge, and 
 in this direction we are to look for further influ- 
 ence on therapeutics. With the now prevailing 
 views, it seems a surprising statement that phthisis
 
 1 6 MEDICINE OF THE FUTURE. 
 
 pulmonalis may be self-limited and end in recovery 
 purely from an intrinsic tendency ; yet, I venture 
 the assertion that the correctness of the statement 
 has been substantiated, and that before many years 
 elapse it will be generally acknowledged to be a 
 clinical fact. How important is this fact in judging 
 of the agency of medicinal, climatic, and hygienic 
 measures in the treatment of this disease ! 
 
 Assuming, as we must, that the only solid basis 
 of therapeutics is clinical experience, and appre- 
 ciating the many and almost insuperable difficulties 
 in the way of educing therefrom conclusions which 
 approximate to the " inflexibility of arithmetic," it 
 is an interesting inquiry, What will be the status of 
 the therapeutical principles which have heretofore 
 governed and of those which now govern the prac- 
 tice of medicine? The medical semi-centenarian 
 has lived through radical changes in medical prac- 
 tice, especially as regards inflammatory affections. 
 The so-called antiphlogistic measures — blood-let- 
 ting, general and local, mercurialization, active 
 counter-irritation, emetics and cathartics, conjoined 
 with starvation diet, which, fifty years ago, were 
 considered as indicated whenever and wherever 
 inflammation was supposed to exist — have of late 
 years been practically repudiated. Formerly the 
 physician who failed to employ them would have
 
 MEDICINE OF THE FUTURE. 
 
 17 
 
 been considered culpable. The physician who 
 should now resort to antiphlogistic measures, as 
 they were formerly employed, could not expect to 
 escape with simply the charge of fogyism ; his 
 practice would be open to censure. Now, was the 
 practice in former days altogether wrong, and is 
 the practice of the present time altogether right ? 
 I shall apply this question to the most potential 
 antiphlogistic measure, namely, blood-letting, with 
 the understanding that my remarks are, to a great- 
 er or less extent, applicable to the other so-called 
 antiphlogistic measures. 
 
 On an occasion which had called together a 
 considerable number of medical practitioners, the 
 question being raised how many lancets could be 
 at the instant exhibited, it so happened that not one 
 of those present had a lancet in his pocket. None 
 had recognized the liability to an emergency which 
 might call for prompt venesection. This occur- 
 rence was on the other side of the Atlantic ; but it 
 would certainly not be fair to infer that the same 
 thing could happen at an assemblage of British 
 practitioners. However that may be, there is not 
 much risk in hazarding a prediction that, long be- 
 fore the expiration of the next half-century, no prac- 
 titioner of medicine will be without a lancet at 
 
 hand for immediate use. There will then be no 
 3
 
 1 8 MEDICINE OF THE FUTURE. 
 
 longer pertinency in the title of a paper written but 
 a few years since by my lamented friend, the late 
 Professor Gross, in reference to venesection, name- 
 ly, " A Lost Art in Surgery." 
 
 I shall not undertake to sustain this prediction 
 by a comparison of past with present experience, 
 collecting data from medical literature, or by ra- 
 tional considerations. I shall adopt a shorter but 
 not less conclusive argument. Blood-letting for a 
 long period entered largely into the practice of 
 medicine. It commended itself to practitioners of 
 sound judgment and large experience, who were 
 good observers. Were they altogether deceived ? 
 Is it, I shall not say probable, but possible, that 
 physicians in the early part of the last half-cen- 
 tury, and for previous centuries, persisted in a 
 measure of treatment which never did good, but 
 always did harm ? These questions involve that 
 argument. Blood-letting must have been produc- 
 tive of more or less benefit, albeit it is potential for 
 harm as well as good. 
 
 A fair conclusion is that, by the abandonment 
 of blood-letting, a useful measure of treatment was 
 given up. It was doubtless employed too indis- 
 criminately and often carried too far. Its dangers 
 and evils were as much overlooked as they are now 
 exaggerated. Its use was not properly regulated
 
 MEDICINE OF THE FUTURE. 
 
 19 
 
 by indications and contra-indications. The time 
 will come (and that ere long, for it is now fore- 
 shadowed) when it will have its proper rank among 
 therapeutic agencies. Physicians will take advan- 
 tage of the promptness and efficiency of its effect 
 in certain conditions of disease, and will observe 
 a proper conservatism as regards its potency for 
 harm as well as good. To carry out the principle 
 of rejecting remedies because they are capable, if 
 used without due discrimination and discretion, of 
 doing harm, would be to emasculate the materia 
 medica. A remedial agent can have but little 
 value if it be not capable of acting injuriously as 
 well as usefully. In the ability to employ poten- 
 tial agencies so judiciously as to secure their good 
 and avoid their evil effects, lies the secret of true 
 success in the practice of medicine. 
 
 I come now to an event in the progress of 
 medicine, already adverted to and characterized 
 as the crowning epoch in the medical history of 
 the last half-century. I refer to bacterial etiology. 
 My own impressions, in respect to the interest and 
 importance of this topic, are such that my remarks 
 will perhaps be considered as illustrative of that 
 tendency to exaggeration and extravagance of utter- 
 ance which is one of the peculiarities of the Ameri- 
 can people. We are entering upon a revolution in
 
 20 MEDICINE OF THE FUTURE. 
 
 medicine. It is bewildering to project the thoughts 
 into the future in order to foresee changes which 
 will be brought about, in the coming half-century, 
 in our knowledge of the causation of diseases and 
 the results as regards their prevention and treat- 
 ment. 
 
 The candid reader of medical history can not but 
 be impressed with the lack of accurate information 
 of the causes of disease. In morbid anatomy, ma- 
 croscopical and microscopical, in symptomatology 
 and clinical description, in differential diagnosis, 
 and in knowledge of the causative connection with 
 each other of different affections, medicine has ad- 
 vanced wonderfully within the last half-century. 
 Can we say as much in behalf of etiology? Put- 
 ting aside communicable diseases, a reviewal of 
 medical literature could leave no doubt as to the 
 answer to this question. How many diseases have 
 been loosely attributed to "taking cold," to physi- 
 cal habits of life, to mental conditions, to climate ; 
 and, when it has seemed irrational to specify caus- 
 ative agencies, it has been necessary to say that 
 they originated spontaneously, overlooking the fact 
 that spontaneity is no more applicable to patho- 
 logical conditions than to any other of the phe- 
 nomena of nature. It is a trite truism to say that 
 all effects have adequate causes. To say that a
 
 MEDICINE OF THE FUTURE. 2 1 
 
 disease has a spontaneous origin is no less a sole- 
 cism than to regard a waterfall as fortuitous, taking 
 no account of gravitation. Instead of saying that 
 certain diseases arise spontaneously, a more honest 
 expression is a simple confession of ignorance. 
 
 For several years there had been glimmerings 
 of the light to be shed upon the causation of a large 
 and important class of diseases which it is conven- 
 ient to distinguish as infectious diseases. Indeed, 
 long before the recent discoveries in bacterial eti- 
 ology, it was apparent that the theory of the agen- 
 cy of living organisms afforded the only rational 
 explanation of certain facts in the history of dis- 
 eases now distinguished as infectious. Nearly 
 fifty years ago, Sir Henry Holland, a philosophical 
 writer, whose contributions to literature may be 
 read to-day with pleasure and profit, advocated 
 " the hypothesis of animalcule-life as a cause of 
 disease." In 1847, James K. Mitchell, of Philadel- 
 phia, published a volume of much interest, in which 
 were collected a host of facts in support of the 
 cryptogamic origin of certain diseases. Other 
 writers, in different countries, anticipated, on ra- 
 tional grounds, the demonstration of the correct- 
 ness of the so-called germ-theory of the causation 
 of diseases. 
 
 I assume it to be a demonstrated truth that
 
 22 MEDICINE OF THE FUTURE. 
 
 the specific causes of certain of the infectious dis- 
 eases are micro-organisms. I do not propose to 
 inquire how many of these diseases have been 
 known to be in this category or to discuss the 
 evidence in regard to diseases which admit of 
 doubt concerning the completeness of the demon- 
 stration. It is enough for my present purpose, 
 that this truth has been demonstrated in but a sin- 
 gle instance. The point which I wish to make is, 
 assuming the truth of the parasitic origin of any 
 one of the infectious diseases, that it is a logical in- 
 ference that this truth is applicable to the other 
 diseases of that class. If relapsing fever be shown 
 to depend on a contaghmi vivum, small-pox and the 
 other eruptive fevers have a similar dependence. 
 If typhoid fever proceed from a specific micro- 
 organism, so does typhus fever. If yellow fever be 
 parasitic, so is intermittent fever. Moreover, the 
 discovery of a specific micro-organism as the cause 
 of a disease, places it in the class of infectious dis- 
 eases, although it had not previously been consid- 
 dered as belonging in this class. Microscopical re- 
 searches have thus lately enlarged this class of dis- 
 eases, and the enlargement is likely to continue. 
 Phthisis pulmonalis was regarded by few, if any, 
 as an infectious disease prior to the discovery of 
 the bacillus tuberculosis. If my reasoning be cor-
 
 MEDICINE OF THE FUTURE. 23 
 
 rect, it is simply a question of time as to the dis- 
 covery of specific organisms for all the infectious 
 diseases. 
 
 It is, to say the least, an innocent indulgence of 
 the imagination to consider the influence of these 
 discoveries upon medicine in the future. Having 
 acquired knowledge of the natural history of the 
 different species of parasitic organisms, a great 
 practical object, of course, is to find means for their 
 destruction within the body. Despite difficulties, 
 this object will be accomplished. The parasiticides 
 in cases of malarial fever were long ago discovered, 
 although it is not certain that the parasite has yet 
 been described. Here is a disease completely un- 
 der control by remedies, the efficacy of which is 
 to be explained by their destructive effect on a spe- 
 cific organism. Imagine all the infectious diseases 
 to be as fully under control as are now the malarial 
 affections ! Is it an exaggeration to say that a revo- 
 lution in medicine would then have taken place ? 
 This revolution will hereafter be dated from the re- 
 cent discoveries in bacterial etiology. 
 
 It may be said that these discoveries do not 
 warrant the glowing thoughts of the future which 
 I have ventured to express, and that, up to the pres- 
 ent time, they are barren as regards practical re- 
 sults. Granted difficulties never so great, when
 
 24 
 
 MEDICINE OF THE FUTURE. 
 
 some of these are overcome, the way will be 
 opened to overcome others more easily. To find 
 an efficient and safe destructive agent for each spe- 
 cies of pathogenic organisms, together with an 
 effectual method in its employment, is not the only 
 object to be kept in view in order to control infec- 
 tious diseases. The presence of parasites is but one 
 factor in the etiology of these diseases. Conditions 
 favorable for the lodgment, growth, multiplication, 
 and colonization of parasitic organisms — conditions 
 which constitute a peculiar predisposition or di- 
 athesis — are not less essential. If these can be re- 
 moved, the control will be as complete as if effected 
 by parasiticides. Ground is as yet hardly broken 
 in this field, and it is useless to speculate concern- 
 ing the future products of its cultivation. It is not 
 improbable that labors in this direction may be 
 more speedily successful than efforts to discover 
 toxical agents which destroy pathogenic organisms, 
 leaving the patient unharmed. 
 
 To say that knowledge of bacterial etiology 
 will lead to effective means for the arrest of in- 
 fectious diseases is not perhaps to indicate the most 
 important way in which this knowledge is to influ- 
 ence medicine in the future. The destruction of 
 organisms outside of the body by disinfectants, 
 and by the removal of all the accessory conditions
 
 MEDICINE OF THE FUTURE. 25 
 
 necessary to their existence, together with their 
 effectual exclusion from the body, may, and in- 
 deed it is more than probable will, reduce the 
 fatality from infectious diseases, in the order of 
 Providence, much sooner than the discovery of 
 effective therapeutic agents. Moreover, there are 
 present intimations of important discoveries re- 
 specting inoculation with attenuated viruses and 
 contagia in order to forestall the development of 
 infectious diseases. Here open up to the imagina- 
 tion the future triumphs of preventive medicine in 
 respect to all classes of disease. The zeal and 
 activity in this department of medicine often, in 
 spite of obstacles arising from popular prejudice 
 and indifference, redound to the glory of the 
 medical profession. 
 
 Putting aside bacteriology, are there not patho- 
 logical conditions, of which little or nothing is now 
 known, which await important developments of 
 knowledge in the future? The spleen must have 
 functions liable to perversions, at present but little 
 understood. Much remains to be learned respect- 
 ing the hepatic functions, and we may look for- 
 ward to the time when the term, biliousness, 
 handed down from Hippocrates and Galen, shall 
 have some definite meaning, and when the liver 
 will no longer be available as a convenient source 
 4
 
 2 6 MEDICINE OF THE FUTURE. 
 
 of ailments, the origin of which is confessedly un- 
 known. Can it be doubted that the pathological 
 conditions of the chylopoetic and the haemato- 
 poetic systems will in due season be elucidated, 
 when will be found the missing link which binds 
 together leucocythaemia, Hodgkins's disease, Addi- 
 son's disease, and pernicious anaemia, and when 
 new toxical agents in the blood will be brought 
 to light? The glands of the stomach, it is esti- 
 mated by Leube, secrete thirty pounds of gastric 
 juice per diem, and the glands of Lieberkiihn, an 
 unknown but undoubtedly a very large quantity 
 of intestinal juice ; yet, • lesions affecting these 
 extensive glandular systems, and their functional 
 disorders, are hardly recognized in the nosolo- 
 gy. Here is a vast and fruitful field for future 
 clinical researches. The thyroid body, the lym- 
 phatic glands, and the supra-renal capsules must 
 have important physiological functions not yet as- 
 certained, and a corresponding importance in pa- 
 thology. When I think of the future discovery of 
 pathological conditions, I connect my thoughts 
 with the reflection, how great has been the influ- 
 ence of the researches of Bright on the doctrines 
 and practice of medicine ; and yet, within my own 
 recollection, the relations of the kidneys to dropsy 
 and uraemia were unknown.
 
 MEDICINE OF THE FUTURE. 27 
 
 I should not do justice to my subject without 
 offering- some thoughts concerning medical litera- 
 ture; medical instruction, and the medical profes- 
 sion of the future. 
 
 With each successive decade in the last half- 
 century, the medical press has been more and more 
 prolific. The fecundity is likely to increase rather 
 than diminish. There is no prospect of a meno- 
 pause. What a progeny may be expected, at the 
 end of the next half-century ! Consider the situa- 
 tion, at the present time, of that unfortunate per- 
 son so often mentioned as the " busy practitioner" ! 
 He is naturally, as is to be hoped, anxious to be 
 au cotirant with French, German, and English medi- 
 cal literature. With each successive month he 
 consults the Index Medicus, " a monthly classified 
 record of the current medical literature of the 
 world." If he be thoroughly discouraged at this 
 day, what must be the state of mind produced by 
 consulting an Index Medicns in the year 1936? The 
 truth is, that, at the present time, and still more in 
 the future, the range of reading and study must be 
 restricted, in a great measure, to limited parts of 
 the vast field of medical literature. 
 
 The multiplicity of medical publications repre- 
 senting real advancement of knowledge in the sev- 
 eral branches of medicine must lead to certain
 
 28 MEDICINE OF THE FUTURE. 
 
 changes, some of which may be called reforms. 
 Clinical studies will, of course, always hold a 
 foremost place among- the means of advancing 
 knowledge of medicine ; but there must be less 
 superfluity of reported cases and less redundancy 
 of details in published histories. A reform in these 
 regards, as may be hoped, will extend to the tedi- 
 ous oral recitals of interesting cases, rendering tire- 
 some the meetings of medical societies and some- 
 times marring the pleasure of social intercourse. 
 The time may come when fewer books* will be 
 written with a view to impress upon credulous 
 readers the superior attainments and skill of their 
 authors as practitioners in some special province 
 of practice. It may be hoped, also, that future pub- 
 lications will abound much less in the profitless 
 minutiae of observations, experiments, and in tabu- 
 lated data, representing often labor without valu- 
 able results. Another reform is the elimination 
 of complicated schematic devices and ingeniously 
 colored diagrams, laden with figures and embel- 
 lished with curved lines. Future authors will 
 be forced not to encumber books with a digest 
 of all the past literature of the subjects treated 
 of. The necessity for condensation and concise- 
 ness will become imperative. It is now true — 
 but future readers will appreciate more fully the
 
 MEDICINE OF THE FUTURE. 
 
 2 9 
 
 truth — that art is too long and life too short for 
 busy practitioners to wade through bulky volumes 
 or Extended articles in order to ascertain whether 
 or not they contain aught of value. It will be 
 requisite that books shall contain a fair synopsis of 
 their contents, so that judgment can be formed be- 
 forehand whether time will be wasted in a careful 
 reading from cover to cover. Compendiums, ana- 
 lytical reviews, and the catalogue raisonne" of libra- 
 ries, of great use at all times, will be indispensable 
 in the future. These and other contrivances must 
 be resorted to for repressing and counteracting 
 the exuberance of medical bibliography. 
 
 Voluminous encyclopedic works have probably 
 had their day. It is doubtful if a French publisher 
 will hereafter be bold enough to repeat an enter- 
 prise like that of the Nouvcau Dictionnaire de Mdde- 
 cine ct de Chirurgie pratiques, which was begun in 
 1864 and, after the publication of thirty-eight oc- 
 tavo volumes, has but lately reached the end of the 
 alphabet. The German work edited by Ziemssen, 
 and entitled a Handbuch — a name which one might 
 suspect to be a pleasantry, if the character of Ger- 
 man writers laid them open to such a suspicion — a 
 translation of which, more pretentiously called an 
 " Encyclopaedia of Practical Medicine," was pub- 
 lished in America, in seventeen volumes, and is un-
 
 30 MEDICINE OF THE FUTURE. 
 
 doubtedly a work of value. But, although several 
 years have elapsed since the last volume was issued, 
 the publishers probably have reason to congratu. 
 late themselves that the work was sold by sub- 
 scription. 
 
 There is reason for thinking that text-books 
 which assume to extend over the whole domain of 
 medicine will soon belong to the past. Owing 
 to the progress in knowledge of diseases, and the 
 developments in etiology, pathology, and thera- 
 peutics which this progress involves, it will soon 
 require not a little hardihood for an author to un- 
 dertake to furnish even a minimum of information 
 that the medical student and the practitioner are 
 expected to acquire of all or a considerable part of 
 the diseases embraced in the nosology. Hereafter 
 the department of medical literature embracing the 
 principles and practice of medicine will consist of 
 works limited to individual diseases or to nosologi- 
 cal divisions. The accumulation within late years 
 of the increasing number of treatises on diseases of 
 the lungs, heart, nervous system, throat and nose, 
 liver, stomach, bowels, kidneys and bladder, the 
 diseases of children, the diseases peculiar to women, 
 eruptive diseases, fevers, gout, etc., render it evi- 
 dent that such works must supersede those intended 
 to cover the whole range of medical practice.
 
 MEDICINE OF THE FUTURE. 31 
 
 Passing from medical literature to medical in- 
 struction, correlative changes in the latter are to 
 be expected. Fifty years ago, it was customary 
 for a professor of medicine to write out in full lect- 
 ures on pathology and practice (sometimes in- 
 cluding physiology) which, with interlineations, 
 were re-read year after year. To this custom the 
 medical professor is indebted for the inimitable work 
 of Watson. The custom now belongs to the past. 
 The progress of medicine has made its continuance 
 impracticable. More teaching and more teachers 
 are indispensable. The amount of teaching and 
 the number of teachers must continue to increase. 
 The whole of general pathology can not longer 
 be incorporated with practical medicine. Special 
 branches require special teachers, and the number 
 of special branches will multiply. 
 
 1 predict that didactic, except as complemental 
 to clinical teaching, will be more and more re- 
 stricted, and perhaps at length be discontinued, 
 recitations and the study of books taking its place. 
 Observation of the phenomena of disease, together 
 with practical exercises in diagnosis and the appli- 
 cations of therapeutics to individual cases, are to the 
 study of medicine what experimental illustrations 
 are to the study of chemistry and physics ; or, not 
 going without the domain of medicine, they are
 
 32 
 
 MEDICINE OF THE FUTURE. 
 
 what the use of the scalpel is in the study of anat- 
 omy, and the use of the microscope, in the study of 
 histology. To point out and explain the pathologi- 
 cal character and diagnostic import of morbid phe- 
 nomena, as manifested in cases of disease under 
 observation, to secure practical familiarity with 
 methods of examination, and to demonstrate the re- 
 sults of practice — these are now, and will be still 
 more in the future, the chief ends of oral instruc- 
 tion in medicine. 
 
 Bedside teaching and practical work in the histo- 
 logical laboratory will henceforth form an essential 
 part of medical instruction. The medical student 
 must not only learn what is already known of the 
 practical applications of microscopy, but he may be 
 incited thereby and qualified to extend the bounda- 
 ries of knowledge in physiology and pathology. 
 The study of the functions of the organs and tissues 
 of the body in health and disease, of etiology, and of 
 therapeutics, must include experiments on lower 
 animals. It is a painful reflection that this study is 
 hampered by penal restrictions in the most enlight- 
 ened country on the globe. Yet this is not a soli- 
 tary instance, within the last half-century, of ob- 
 struction to the progress of medicine by popular 
 prejudice based on ignorance. It is not very long 
 since the study of practical anatomy involved the
 
 MEDICINE OF THE FUTURE. 
 
 33 
 
 necessity of either committing or being accessory to 
 what the law of the land declared to be felony. The 
 dissection of the human body, in the eyes of legisla- 
 tors, denoted a ghoul-like propensity developed by 
 the study of medicine. The dissemination of popu- 
 lar knowledge has effaced this stigma in most civi- 
 lized countries. So will it be in the future with what 
 we may call experimental medicine. The profession 
 in America look to the mother-country, as well as 
 to France and Germany, for the active employment 
 of all proper means for the advancement of medical 
 knowledge. English jurisprudence, near the end of 
 the nineteenth century, in an attitude of hostility 
 to investigations inspired by humanity and having 
 no motive or object save the welfare of mankind, 
 is indeed a strange spectacle. As evidence of a 
 prevailing popular sentiment of justice toward the 
 medical profession, it is to be hoped that British 
 novelists will ere long find more worthy objects for 
 the exercise of the imagination than the portrayal 
 of a vivisector as a person to be shunned or de- 
 spised. 
 
 The medical profession of the future — this topic 
 offers scope enough for thought, but my temerity 
 is not sufficient for me to trespass except for a few 
 moments on your further indulgence. 
 
 The ideal physician of the future, representing
 
 34 MEDICINE OF THE FUTURE. 
 
 an advanced stage in the progress of medicine, will 
 be, it is to be presumed, a better practitioner than 
 the physician of our time. His practice will exem- 
 plify more knowledge of pathology and etiology, 
 together with advancement in therapeutics and 
 prophylaxis. We can fancy that, on appropriate 
 occasions, at the end of the next half-century, he 
 will review past medical history, and with com- 
 placency, as viewed from his standpoint, amplify 
 on the defects and errors of the practitioners who 
 represent the present stage of medical progress. 
 
 The progress of medicine induces, slowly but 
 surely, changes in popular ideas. The physician 
 of the future will, perhaps, not be better appreciated, 
 but there will be a truer estimate of medical knowl- 
 edge and of the medical profession. It is a pleas- 
 ant thought that hereafter the practice of medicine 
 may not be so closely interwoven as hitherto, in 
 the popular mind, with the use of drugs. The time 
 may come when the visits of the physician will not 
 as a matter of course involve the co-operation of the 
 pharmacist ; when medical prescriptions will be di- 
 vested of all mystery and have no force in the way 
 of fortifying the confidence of the patient. The 
 medical profession will have reached a high ideal 
 position when the physician, guided by his knowl- 
 edge of diagnosis, the natural history of diseases,
 
 MEDICINE OF THE FUTURE. 
 
 35 
 
 and existing therapeutic resources, may, with nei- 
 ther self-distrust nor the distrust of others, treat 
 an ' acute disease by hygienic measures without 
 potent medication. When this time comes, a sys- 
 tem of practice which assumes to substitute me- 
 dicinal dynamics for the vis medicatrix natures will 
 have been added to the list of by-gone medical de- 
 lusions. 
 
 But we must not look into the future exclusively 
 in the light of optimism. Are there no prospective 
 dangers incident to the progress of medicine? Let 
 me briefly advert to one source of apprehension. 
 
 The unavoidable subdivision of medical litera- 
 ture and medical instruction into special depart- 
 ments makes necessary, to a certain extent, special- 
 ism in the practice of medicine. It is certain that 
 this will not lessen, but increase, in the near fu- 
 ture ; and it is important to think of possible emer- 
 gencies which are even now foreshadowed. Spe- 
 cialism conduces to the advancement of knowl- 
 edge. It behooves us, however, to consider, were 
 the practice of medicine to be given up to spe- 
 cialists, what would become of the medical pro- 
 fession. With due appreciation of services devoted 
 to special branches of medical knowledge, there 
 are tendencies pertaining to the practice of a spe- 
 cialty that should not be overlooked. I shall only
 
 36 MEDICINE OF THE FUTURE. 
 
 allude to the danger of what may be called profes- 
 sional demoralization. I do not care to speak of 
 those who adopt a specialty for other than the mo- 
 tives which have governed worthy physicians in 
 all ages. A dangerous tendency is to such a limi- 
 tation to a specialty as will lead to withdrawal from 
 the common interests of the profession. A medi- 
 cal specialist should not thereby, in his sentiments 
 and conduct, be any the less a physician ; the hon- 
 or, dignity, and usefulness of the profession, as a 
 whole, should be as sacred in his estimation as if 
 he were not a specialist. If the effect of specialism 
 be otherwise, alas for the medical profession of the 
 future, as regards the respect of others and the self- 
 respect of its members ! For one, I can not believe 
 that, in the order of Providence, the destiny of this 
 profession is its degradation. The history of medi- 
 cine has made the medical profession most honor- 
 able, and I believe that it has a glorious future. 
 
 Mr. President, I can not adequately express my 
 appreciation of the honor of an invitation to read 
 an address on medicine at a meeting of the British 
 Medical Association. I am well aware that the in- 
 vitation was intended, not as a personal compliment 
 so much as a manifestation of good-will toward the 
 medical profession of the United States, where the
 
 MEDICINE OF THE FUTURE. 37 
 
 same language is spoken, a common literature en- 
 joyed, and where the institutions, literary, educa- 
 tional, scientific, philanthropic, and political, are 
 modeled largely after those of the parent country. 
 On behalf of my American brethren I tender to 
 yourself and to the members of the British Medical 
 Association sincere thanks. The gratification with 
 which the invitation was accepted would have been 
 without any drawback could I have felt confident 
 of my ability to do justice to the opportunity and 
 the occasion.
 
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