TENDENCIES IN MEDICINE 
THE PRESIDENT'S ADDRESS 
DELIVERED BEFORE THE 
Association of American Physicians 
Washington, D. C., May 4,1897 
BY 
J. M. DaCOSTA, M.D., LL.D. 
PRESIDENT OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA 
1897 TENDENCIES IN MEDICINE 
It is expected of the President of your Association 
that he offer some remarks as introductory to the scientific 
papers that are to occupy your attention, and every pre- 
siding officer has done so, expressing himself on subjects 
for some time in his mind or to which he has been recently 
giving heed. Thus, diversified and excellent addresses 
have been made, some treating of medicine and its aims 
in a broad, philosophical spirit; some reviewing its 
achievements; others giving most erudite and valuable 
historical information. In my turn I ask that you will 
indulge me if I present a few thoughts on what seem to 
me in our science the best tendencies of the day, as well 
as on certain causes that, with all the wonderful work 
being done, and with the immense energy and industry 
of the devoted laborers in four continents, retard its 
still broader and steadier development. 
The greatest advance of our time-it seems trite to men- 
tion it to such an assembly-is the ardent study of the 
causation of disease. Students have speculated in all 
ages on the causes of disease; but these have been, for the 
most part, half-hearted speculations, made so by the feel- 
ing of impossibility of reaching a conclusion, or dogmatic assertions that, believed in for a time, soon became of inter- 
est only to the curious searchers for fragments on the shelv- 
ing beach of science. Now, the recognition of minute 
organisms, their study, their artificial culture and modes 
of growth, their secretions, their chemical character, their 
likes, their antagonisms, have let us into the secrets of 
another world and are showing us the way in which infec- 
tive maladies originate and the laws they obey. We are 
looking for infection in every disease; we are often keenly 
pursuing it where it probably does not exist; at all events, 
not in the shape of bacteria, which in our day we accept 
as a term almost synonymous with infection. A sense 
of causation, formerly deficient, has been replaced by a 
most acute sense, and by a desire for unrelenting search. 
What is still greatly needed is, I think, an appreciation of 
how infection may light up slow processes and lead to 
structural complications, such as are found, for instance, in 
the exanthemata. We have also much to learn of bacteria 
that exist normally becoming abnormal in certain per- 
verted conditions, either in manifold growth, as happens 
with the bacillus coli communis, or in character. What 
we consider the cause may thus be only the consequences 
of disease. The soil and its forces, too, are to be studied 
and critically examined. 
But the power of this little, invisible world is mighty. 
It is told of Napoleon that he could never understand the 
fame of Cuvier. He spoke of him, with something like 
contempt, as only occupied with small things. Yet 
smaller things conquered even him, the great conqueror. 
2 It was the plague bacillus, not Sir Sidney Smith, that 
compelled him finally to leave Syria and give up his 
dream of subduing the East, like another Alexander. 
Other than mere bacteriological work forms a most val- 
liable part of the contribution of the laboratory to the 
investigation of disease, and in the last decade has placed 
this investigation on a much higher plane. The micro- 
scopical and chemical examinations of the secretions and 
excretions and of the blood have become our daily duty. 
The chemical examinations, which, dealing, as they may 
be made to do, with the constantly varying problems of 
life in disease, have been temporarily overshadowed by 
the ardor of bacteriological research, will, with widening 
fields, resume their former prominence. The time is indeed 
at hand in which, without the ready access to a laboratory 
manned by experts in all these lines, or the association 
with a trained laboratory assistant, no physician can do 
his patients, himself, or his science justice. 
Closely connected with the laboratory investigation of 
disease, especially with its chemical investigation, is the 
study of the effects of the products generated by decom- 
position of albuminous matter, producing, when developed 
in the dead body, the substances known as ptomaines, 
when in the living body, as leukomaines. The recognition 
of these agents, so frequently poisonous, is explaining 
many obscure processes, is leading to new and close 
scrutiny of others and to search after means of neutral- 
izing their toxic influence. It is with pride that this 
Association can view the history of this branch of re- 
3 search, for the fruits it has yielded have been largely 
gathered by the efforts of some of its own members. 
Another of the best results of the achievements of our 
time is seen in the effacement of the strict division between 
medicine and surgery, or rather in the recognition that 
there are no lines separating them, but lines becoming con- 
tinuous, on which joint action proceeds. We see this in 
the whole clinical history of appendicitis and its progres- 
sive unfolding; the more the medical part is studied and 
rendered precise, the more exact become the indications for 
operation and the appreciation of the chances of this. 
The same may be said of abscess and of tubercle of the 
kidney; of the investigations of the character of effusions 
into pleural, or pericardial, or peritoneal cavity; and of 
many other well-known conditions that surgeons and phy- 
sicians are now studying together. This new tendency 
is sure to counteract not only the excessive specialism of 
our day, but to give us once more broader physicians 
and surgeons, taking the keenest interest in each 
other's work. 
One of the greatest improvements in our generation is 
in the much better appreciation and larger use of hygienic 
means, of systematic exercise, of baths, of regulated rest, 
of out-door life. Then, too, when medicines are given 
they are much more generally used singly, with a view to 
their direct effect, and not in excessive combination. 
Moreover, the substitution of extracts and of active prin- 
ciples for many of the nauseous drugs has taken away the 
terror and disgust with which medicines were regarded. 
4 It is, from a pharmaceutical point of view, at least, no 
longer a punishment to be ill. The satire of Moliere is 
lost to the playgoers of our generation. The highly appre- 
ciated answer of the Bachelor of Medicine, when exam- 
ined for his doctor's degree, that the remedies are always 
" Clysterium donare, postea seignare, eusuita purgare," 
would fall at present on totally unsympathetic ears; for 
now there are delightful capsules, and triturates, and pills 
of aesthetic colors-" dear little piuk pills," as I have 
heard them called, though the dear little pills happened to 
contain strychnine. And the boy of the period is not 
tempted to view an open window as the only means of 
getting rid of the hated bottle; he may, indeed, want to 
take too much of it, because, with all its potency, it is 
sweet and pleasant. 
The tendency of our time is to endeavor to over- 
come disease, and not merely to observe and palliate 
its ravages. 
We are going back to the doctrines of our forefathers; 
abandoned for a time, because, with an expanding knowl- 
edge from the study of pathology, the means they pos- 
sessed were found to be, for the most part, totally inade- 
quate. Thus there was a period of nihilism and expectancy 
in therapeutics. But so-called rational expectancy is but 
a confession of impotency. Now, the tendency is once 
more aggressive. We are trying directly to choke or 
to subvert morbid action, and doing this partly through 
the old, transmitted remedies of former generations, but 
employed with a better understanding of their real quali- 
5 ties, partly by new agents furnished by chemistry and by 
constant research in other fields. Of the former, the freer 
and more scientific administration of digitalis may be taken 
as an illustration; and the use of mercury, though in a 
different manner, is infinitely more prevalent than it was 
some years ago. To bleeding, too, I, for one, believe that 
we shall return; only it will not be the mere abstraction of 
blood perverted by disease, but there will be, with this, 
immediate attempts at the reconstruction of the blood 
by supplying it with the proper saline fluid and other 
ingredients. In the second class, the bromides, chloral, 
the nitrites, and nitroglycerin are prominent, as is a 
whole group of antiseptic agents. Many of these-it 
is especially true of the nitrites-have come to us from 
the physiological laboratory. One of the most inter- 
esting attempts at radical therapeutics is the endeavor 
to counteract the bacteria of disease by substances that 
form in the body which neutralize their toxic products. 
This antitoxin treatment is brilliant and hopeful, and 
is being tried in many affections, pre-eminently in 
diphtheria, in tetanus, and in erysipelas. It cannot 
be said that as yet it has led to any great results, though 
the evidence is decidedly in its favor in diphtheria. It 
seems scarcely worth while to push it in erysipelas-at 
least in erysipelas that the physician sees-for the mortality 
in this is, under any treatment, but very slight. How 
valuable the antitoxins will prove as preventives remains 
also to be solved. More productive thus far has been the 
use of attenuated virus, as, for instance, in Pasteur's treat- 
6 ment of hydrophobia; the influence in cholera, in yellow 
fever, in bubonic plague, is now under keen observation. 
The effects on tuberculosis must be taken thus far as the 
expression of hope rather than of fact. The success of 
thyroid extract in the treatment of myxoedema is leading 
to the close investigation of the active principles supplied 
by other ductless glands. The next decade will prove 
whether the X-rays, which are making such wonderful 
additions to diagnosis, will also have their therapeutic 
triumphs. In it, too, we may look for some striking de- 
velopments of suggestion, not only as explaining mental 
and morbid processes - what more extraordinary and 
thought-starting, for instance, than the recently tested 
production of special cutaneous affections by it ?-but as 
a harnessed therapeutic force. All this is in the line of 
present investigation; and there will be much disappoint- 
ment and wasted labor in particular points, but it is not 
too sanguine to believe that there will be also a solid out- 
come which will immensely advance scientific medicine. 
There are, with all these tendencies of our day that work 
for good, some which, whether growing out of them or 
whether the exaggeration of old hindrances, have to be, in 
the interest of true science, strenuously guarded against. 
One that is very evident is the tendency to immediate gen- 
eralization. The discovery of every new bacterium is 
supposed to revolutionize instantly the science of medi- 
cine, and is announced with all the air of the unexpected- 
ness of genius. Fortunately or unfortunately, one may 
be discovered every day, and a man may thus find himself 
7 with three hundred and sixty-five opinions on the tenets 
of his art in the course of the year; but this would not 
daunt the enthusiasm of the insatiate generalizer: 
"Ten thousand great ideas filled his mind, 
But with the clouds they fled, and left no trace behind." 
Fixity of opinion in medicine is a virtue, if the mind 
remain open to proof and be in sympathy with advance; 
and it is this freshness of mind, joined to good judg- 
ment, through which is best estimated the true value 
of the many facts constantly discovered in an advancing 
science like ours. Clinical medicine, indeed, must con- 
tinue to be the final court of appeal for the purposes of 
the practitioner of medicine. Before that court will come 
and be listened to with sympathetic interest, as eloquent 
advocates, those who are presenting the claims of special 
studies. But these must be well supported and judged in 
their bearing on the whole before new laws are laid down. 
And we see that the more we investigate and the more we 
know the more will old questions assume different aspects, 
the more they will have to be retested; there is no finality 
-there can be none-in medicine. When the last word 
is spoken we shall have a perfect science; until then there 
must remain for us a certain amount of empiricism, espe- 
cially in treatment. 
There is no doubt that, considering the amount of work 
done and recorded, medicine-especially clinical medicine 
-would be much more advanced if the records were dif- 
ferently made, and were not so vague as they often are. 
8 What is more provoking than to see constantly such loose 
statements as this: "The examination was negative." 
Negative as to what? If applied to the action of an 
organ, as to what part of its action ? If to secretions, to 
what part of their constituents? How much easier to 
say, even if it have been an incomplete examination, for 
what exactly they were investigated, and how much more 
certain to be of use for comparison in similar cases. Worse 
still is it with the records of treatment. This is an ever- 
recurring expression : " The usual treatment was em- 
ployed." I saw this in a recent volume of Transactions 
with reference to the congestion of the lungs in typhoid 
fever. What is meant? Is there such a thing as a fixed 
treatment for it the world over ? It might mean dry cups 
to some; ammonia, turpentine, digitalis, or yet different 
things to others. Then the utter absence of mention of 
doses makes it impossible to say whether any remedy 
was fully tested, or to compare its action when given 
in small or in large quantities.- For very many pur- 
poses records, as published, are valueless ; in truth, they 
impede progress, and a little care would make it other- 
wise. 
Then there are records which, made even to the full 
limit of industrious exhaustion, are so badly and con- 
fusedly presented that they bury themselves from the 
start. A little more time spent on their expression might 
make them absolute and convincing. It would be, indeed, 
well if in all our professional literature there were some- 
thing more of the learning of the scholar and the clearness 
9 of the literary artist; men who followed the master, 
Harvey, in other points besides profound and 'productive 
research. A few more Watsons and Pagets, Trousseaus 
and Hyrtls would make knowledge easier to obtain, more 
constantly with us, forming much more a part of our daily 
life and application. It is true that if, in our science, we 
must choose between profound inquiry and its clear enun- 
ciation, we shall choose the former. It is a pity, and it is 
unnecessary, that there should be any occasion for a choice. 
The French, with their lucidness in scientific matters, set 
all other nations an example. The countrymen of Goethe, 
foremost in investigation, following his avowed contemp- 
tuous indifference to style, are the greatest sinners against 
clearness and vivid expression. They evidently believe 
in the reverse of the thought with which Johnson excused 
the inaccuracies in Goldsmith's Animated Nature, that, if 
he once began to make experiments, life would be too 
short for him to get his book written. 
One more tendency of the day let me notice, which is 
not for good, and undoubtedly retards progress. It is the 
excessive publication of half-knowledge, of doubtful fact, 
and of loose inquiry. The propensity for authorship is 
an old disease, but it has assumed a development commen- 
surate with the prodigious development of everything else 
in the age in which we live. It is harmless in journalism, 
less so in literature, but positively dangerous in science; 
for it fills this with immature or false observation, and 
takes the time of others to remove the obstructions placed 
in the stream of knowledge. With some, want of suffi- 
10 cient training leads to it and absence of inquiry into what 
has already been ascertained; in others, it proceeds from 
a girl-like genius that, in place of letter-writing, pours 
itself out in medical periodicals, fascinated by penning 
sentences full of pseudo-scientific commonplace. It is far 
from being a disease only of the untried or ignorant; famed 
workers, too, may succumb to it, listening, perhaps, to the 
entreaties of friendly and sleepless editors. Who knows 
that it is not, after all, a physiological function, giving 
full play to brain-centres in very rare use-centres situated 
in what Oliver Wendell Holmes has called the idiotic 
area of the brain. 
But whatever the retarding influences, they are not to 
any extent checking the onward course of medicine. The 
numerous inquiries, the keen experimentation and close 
research, the general thoughtfulness, are developing a 
resistless scientific method; resistless because it is true. 
Medicine is no longer an art founded only upon empirical 
observation, no longer a purely deductive science; it is 
becoming also an inductive one. The great body of the 
community is touched with friendly interest in watching 
its growth. With the advance of the scientific method 
special systems are crumbling; future ones are impossible. 
There can be no more pathies; the general intelligence 
will prevent it; for educated men are recognizing the 
broad base on which medicine is resting, and that truth is 
sought in it by the same means that are used in physics 
aud in the highest development of other sciences. In our 
midst with all this, conviction is becoming clearer, purpose 
11 waxing more resolute. We see, without pang, castles which 
have crowned rocks being turned into dismantled memo- 
ries, because we know that something stronger, that will 
defy all time, will stand ultimately on the old command- 
ing sites. Everyone of us must work until he discovers 
in his work his true self, and then aid with what he finds 
he can do best in helping all. With everyone of us there 
is a mission to assist the general advance. 
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