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Lectures and Addresses.

THE MEDICAL PROFESSION

AT THE CLOSE OF THE NINETEENTH CENTURY.
AN ADDRESS DELIVERED BEFORE

THE NEW YORK STATE MEDICAL ASSOCIATION
AT ITS THIRTEENTH ANNUAL MEETING,
October 14, 1896.

BY CHARLES PHELPS, M. D.,

NEW YORK COUNTY,

NOW PRESIDENT OF THE ASSOCIATION.

IT has come to be the custom in the medical profession on formal occasion to rehearse its later triumphs, to glorify its present as an Augustan age, and to foresee its future in brilliant lights, through which are cast no shadows of distrust. It is a custom rightly honored in the observance. The science and art of medicine hold a position of honor and consideration, dependent upon extraordinary advances on both medical and surgical lines, which is unparalleled in their history. We may well felicitate ourselves that as a profession we have not lagged behind in the revival of intellectual activity which distinguishes the present era in science. It is proper that we should celebrate with pomp of words the splendid achievements of our immediate predecessors and of our contemporaries; it is pardonable if our exultation has been sometimes voiced in too magniloquent and resounding phrases, and not always tempered by a generous remembrance of the struggles and successes of a remoter time.

question, and its continued advancement a matter of record. The successive discoveries of the circulation of the blood, of the efficacy of vaccination, and of the possible annihilation of pain by anæsthesia are imposing landmarks along the path which has been traversed; and all through this time the gradual evolution of a rational system of treatment of disease and the progressive improvement of methods of surgical interference are sufficient evidence that the advance has been fairly uninterrupted. The recent detection of pathogenic germs, the heretofore invisible host which barred the way to surgeon and physician alike, was but one of the great victories in the war which for a century and more has been persistently waged against the invasion and progress of disease. It has been followed by an extraordinary amount of fruitful research, widely distributed, both in this country and abroad, and the influence which it has exerted in the study of pathology and in the practice of therapeutics has not been paralleled by that of any previous discovery in the domain of medical science.

This energetic cultivation of a special scientific field, and the affluence of its results, are not to be regarded as isolated phenomena apart from the general trend of thought and intellectual activity in these later years of the nineteenth century. The age in which we live is eminently practical, and attention has been engrossed in studies of science as distinguished from letters, science as applied to the discovery of such facts as have a definite material value.

The appreciation of intellectual culture, either as an end sufficient in itself, or as a means to the better accomplishment of ultimate results, has been lessened; its necessity as a foundation for technical acquirement is scarcely recognized or inculcated. In American colleges and universities, even of the higher grade, the

Reflection naturally succeeds to exultation. After a decade of mutual congratulations, the time is fitting for a consideration of the forces, both extraneous and inherent, which have conspired to enhance the usefulness and renown of the medical calling, and for an estimation of the several and diverse tendencies toward good and evil which dominate it now, and which, un-extent of classical and rhetorical study demanded has checked, are destined to shape its future.

been more and more circumscribed, until undergraduThe present supposed renaissance of medical art is ates are now practically permitted to pursue such exbut a somewhat sudden increase in the energy of an clusive lines of work as in their unguided opinion perirregular but ceaseless development. Its waves of prog- tain directly to their future occupation in life. The ress, which have never stayed and have gathered un- surrounding conditions of mental action, and perhaps noted strength, have simply chanced to break upon the the contemporaneous mental constitution, incite to scishores of our time with unwonted force. It may be un-entific investigation rather than to endeavor in the certain whether surgery was prehistorically progressive, higher planes of literature. or whether within the limits of tradition from century to century its advances have been always manifest or without recession. It is unimportant to the present consideration of medical or surgical art to disentangle its history from early fable and mythological romance to determine to what extent it existed in an epoch of barbarism, or in a subsequent era of mediaval superstition, or even to define the period in which it may be deemed to have acquired a scientific basis. From the seventeenth century, at least, the inclusion of medicine in the field of positive if not exact science is beyond

It follows that the arts most sedulously wrought and successfully developed have been mechanical, industrial, or, in some sort, utilitarian rather than æsthetic. The gentler arts of oratory and poesy, and of letters, have not only failed of advancement, but have suffered decadence. The distinguished orator of to-day makes merry with postprandial jest. The voices which come from the tribune, the forum, or the pulpit have lost in resonance and sweetness; and the persuasive charm, the impassioned and resistless force of eloquence which beguiled or compelled the minds of men, exists only in

memory, or is but faintly shadowed in a printed page. The poetry of Bryant and Longfellow belongs to a rapidly receding past. In the general field of letters, an epoch which is impressed with the genius of Irving and Curtis, which recalls the delicacy and refinement of the period of Addison and Steele, has been definitely closed with the death of Holmes.

germ was an unknown and unsuspected enemy always ready to fall upon a point exposed. From first to last, chance was necessarily a potential factor.

In both war and surgery chance and genius have come to play a smaller part. In modern military art, each element of a complex organization, every detail of formation, movement, or maintenance, is rigorously perfected, the destructive power of arms and ordnance is accurately determined, the value of position exactly

It is not to be assumed that the altars of the Muses are deserted, or that they who stand outside the temple gates are ignorant or of indifferent mind. Popular in-appreciated, and the issue of battle predicated with altelligence is more acute, and popular education broader than ever before; journalism is clever; literary work of higher or more pretentious character is respectable; and the best of literary production, of whatsoever value it may be, does not lack popular appreciation. At the same time, the urgent demand is for tangible results in the betterment of the physical conditions of existence, and in no other direction has the outcome of intellectual force been so conspicuously great. The absolute present, no less than the immediate future, is still pregnant with marvels of mechanism to be derived from the further study and application of the laws of physical science. The impossibilities of yesterday and the improbabilities of to-day are the assured certainties of tomorrow. No limit has yet been fixed to the applications of electricity, steam, or chemical forces in the practical prolongation of life through the annihilation of time and space; no engineering problem has yet been found incapable of solution; no anticipation of mechanical progress, fairly formed, however extravagant, has failed of realization. In every phase, life has been increased in value by more thoroughly satisfying its necessities, diminishing its pains, and increasing its pleasures.

most mathematical precision. In the field of surgery, diagnosis, prognosis, and treatment are now founded upon an equally complete mastery of all the elements of a case, derived from a minute knowledge of pathology and a critical and laborious observation of clinical phenomena. If surgical science is not yet exact, and the results of surgical practice are still far from certain, it is in part because the study of elemental facts is incomplete. Another reason exists in the various manifestations of nervous and psychic conditions which are essentially incapable of formulation. The impossibility of predicating the degree of shock which will result from the operative destruction of a given amount of tissue, or of determining the extent of lesion from the severity of a chill, or of solving many similar problems, is probably absolute; but there are lines of study which still promise practical results, and which are still unexplored or not yet followed to the end. The present status of surgery, as well as of medicine, is to be ascribed to the careful observation and exhaustive investigation of details, and to a certain extent to a consequént subdivision of labor. Its immediate advances must depend upon a persistence in the same methods. The general acceptance of this proposition determines the most important tendency of both medical and surgical work.

The existing inclination of the professional mind toward methodical observation and the study of rudimental facts has been impressed with certain character

It is not only natural, but inevitable, in an age characteristically occupied with the improvement of physical conditions, that the art most directly concerned with the integrity and prolongation of life, without which all other material advantage is naught, should command great attention, make great progress, and receive great honor. This art was at one time pursued as was the artistics which equally reflect the spirit of the age. It is of war. Then, as now, great care was taken to learn the dispositions of the enemy; but afterward the campaign was planned and battle given under widely diverse conditions. Strategy in war was brilliant, daring, but of necessity much was left to the arbitrament of fortune. In time of action, arms and ammunition were of uncertain range, and their execution more uncertain still; and in the end, victory was often gained by some inspiration of genius or by some happy chance. In surgery, diagnosis was often made in the absence of positive data with an accuracy which was marvelous, and by an exercise of the highest mental powers, which seemed like intuition. Operations were boldly conceived, and the genius of the surgeon often turned the scale when danger threatened; but in practice, medication was profuse and empirical, instruments were often illy adapted to their purpose, and the pyogenic

directed not only to scientific induction, but largely to the accomplishment of immediately practical results, and it is generally diffused through the body of the profession, within the limits of individual capacity and opportunity. The discovery of micro-organisms and of ptomaines and leucomaines is hardly recent, but the recognition of their real nature and of their pathic relations is almost within the present generation. The work of bacteriologists since the identification of the anthrax bacillus by Davaine and Pasteur, scarcely more than twenty-five years ago, has been largely devoted to establishing the dependence of various diseases upon the action of specific bacteria and to attempts to evolve means of cure by specific methods. These efforts have met with more or less success, but even when the result has been problematical they have equally enchained popular attention and stimulated professional labor. It

may be still a question whether Koch or Edson has formulated a cure for tuberculosis or Pasteur for rabies, or whether the treatment suggested by Behring and perfected by Roux will prove effectual in cases of diphtheria, but there can be no doubt that the work of these distinguished pathologists is illustrative of the practical nature of investigations which are in progress at the present time.

ods for their cure. The identification of individual diseases with specific micro-organisms still goes on, and efforts to make the poison its own antidote are still unwearied.

achievement of contemporaneous surgery; it has enormously broadened the scope of operative interference, and by diminishing danger has correspondingly increased the applicability of procedures already established. It is typical of present methods of minute and laborious investigation directed to distinctly practical results. It is also strikingly illustrative of the gradual processes by which exact knowledge has been attained, and, incidentally, of the progressive improvements in practice which have often anticipated a comprehension of the facts or principles upon which they were founded.

The recognition of the pathogenic germ in diphtheria has been but just now succeeded by the discovery of a process of inoculation which promises the most brilliant curative results. The established dependence The original discovery of the existence of bacteria of the process of suppuration upon the presence of and of the animal alkaloids, the gradual determination streptococci has revolutionized surgical practice. In this of their true character, the coincident study of organic instance the detection of a pyogenic germ has been folchemistry in its relation to therapeusis, and the experi- lowed not only by a logical method of cure, but of absomentation in physiology, which afforded such brilliant lute prevention. It is probably the most conspicuous | results in the middle of the century, were not less important and demanded no less eminent intellectual capacity. These preliminary steps toward the more exact prevention or control of disease are perhaps entitled to an even higher rank in the scale of intellectual attainment than those which have been lately taken nearer to the goal. They were advances made in a light but feebly reflected from the achievements of the past-the light in which the work of the present must be always done, and which grows always brighter in the lapse of time. The explorers and discoverers of generations so little past, so near in time, yet so far away in the progress of events, must command still profounder admiration for the singleness of purpose with which their successes were attained. They were content to arrive at truth and to follow it so far as they might, but the fruition of their labors was reserved for their successors who were to build upon the foundation which they had laid. Their measure of fame, as fame is reckoned, was not great; the nature of their researches appealed to but a limited number of their colleagues; and beyond the profession they were scarcely known.

In days not long gone by, but while pyogenic germs were yet undiscovered, and before aseptic laws had yet been formulated or antiseptic fluids were known, Dr. Marion Sims not only did gynecological laparotomies, as Kimball and the Atlees had done before him, but urged upon surgeons the practicability and safety of similar operations for abdominal traumatisms, now counted, perhaps, the highest achievement of aseptic surgery. Dr. James R. Wood had even earlier obtained remarkable results by the open treatment of wounds and the strictest attention to cleanliness as it was then under

The present system of aseptic surgery has resolved itself into an attempt to reach an ideal condition of cleanliness by the employment of specific agencies. The immense advantage gained by present methods of operation and treatment through bacteriological studies has not been derived from the discovery of new principles, but from the more perfect application permitted of those already established. It was known that stagnant pus caused a local or general poison, and that open wounds and free drainage, thorough ablution and general clean

It is evident that the present disposition to direct medical and surgical investigation straight to its ulti-stood. mate object, the cure of disease, while it has grown out of the mental attitude characteristic of the time, has been greatly strengthened by the fact that conditions have been made favorable by work previously accomplished. Physiologists and microscopists, clinicians and pathologists, have so thoroughly established premises that the time has been ripe for conclusions. They have followed convergent lines, which have at last so far merged in one another as to form a broadened course, in which persistence has disclosed the possibilities which we have seen so largely realized. The story of the bac-liness were essential factors in its prevention or cure. teria, which it has taken nearly two centuries to learn and to which the study of many sciences has been tributary, their history and classification, their life and death, and their pathogenic potentialities, had become well known when contemporary investigators were enabled to write the final chapter, which reveals in these atoms the proximate cause of disease, and in some instances to touch the limit which has been set to human knowledge in this direction by the discovery of specific meth

There has been added to these, as a result of much labor in bacteriological and chemical investigation, a knowledge of the proximate cause of suppuration, of the necessity of sterilization for prophylaxis, and of the use of chemical germicides in septic conditions.

Careful and laborious investigations, founded upon gradually and progressively acquired knowledge of facts or principles, and tending to directly practical results, are not confined to bacteriology. Closer study of both

If the magnitude

gross and minute pathology has afforded a basis for more multiplied to an indefinite extent.
accurate clinical observation. The multiplication of
medical journals had further stimulated clinical re-
search. It has enabled a multitude of practitioners of
limited experience to record cases which to them seem
of great importance, and if the record is sometimes
of no great service to the profession directly, it is in-
directly of the greatest value through its reflex influ-
ence upon the writer. In no other way can men learn
their own deficiencies as observers, or establish the
habit of minute and precise, yet comprehensive, nota-
tion of symptoms, which enables them to profit in the
light of experience. The Baconian aphorism applies:
"Reading maketh a full man; conference a ready man;
and writing an exact man." Publication is like ritual-
ism, perhaps not essential to the end in view, but a
necessary stimulus to exertion.

of the discoveries which have been made in the study
of bacteria and of the animal alkaloids has tended to
obscure the importance of, and to lessen interest in, the
progress which is being made in other departments of
medical science, it is to be remembered that all diseases
have not yet been traced to the influence of micro-
organisms, and that all treatment is not yet to be
founded upon the use of germicides.

All the agencies which conspire to render diagnosis more exact, increase the precision of treatmentthe point at which the science is merged in the art of medicine, the end of all professional striving toward its ultimate object, the prolongation of life. Even a simple mechanical instrumentality, the introduction of the clinical thermometer, has so contributed to the certainty of diagnosis, and in many instances so directly guides the course of treatment, that it may be properly ranked with the most important factors in medical progress.

The progressive improvement in methods employed for the prevention and cure of disease has not only followed in the train of more exact diagnosis, but in certain directions has resulted from the direct fulfillment of clinical indications, independent of their origin. Bacteriological studies have unquestionably transcended in importance all other sources of prophylactic or therapeutic advantage. The discovery of facts which have reduced sanitation and public hygiene to an almost exact science, and of the laws which govern the inception and development of infective diseases, have in themselves alone effected a greater saving of human life than have all other recent advances in medicine combined; but an estimate of the progress of therapeusis would be inadequate which failed to recognize the service which has been rendered in other ways, which are to be accounted minor only by comparison.

The use of the Murphy button and that of Maunsell's method of circular enterorrhaphy, which have added incalculably to the safety of operation, exemplify the application of the nicest mechanical skill to the relief of an obvious difficulty without having been presuggested by other considerations. The synthetic products with absolutely definite therapeutic properties, which are the fruit of research in organic chemistry, and which have greatly contributed to precision in medication, are equally typical of the direct interposition of an allied art, uninspired by ætiological investigation, in the relief of morbid conditions. Such examples could be

The position which has been achieved by the medical art in the contemporaneous field of labor is a not more conspicuous fact than its complement, that it has been due to the individual contributions of a vast number of collaborators in all ranks of the profession. There have been, and are still, not only a great number of persons engaged in original investigation in both theoretical and applied science, but in consequence of the very general diffusion of technical knowledge the distinction between leaders and followers, while not entirely lost, has become much less sharply defined; and the professional work which entails the greatest responsibility and confers the greatest honor, which was once reserved to the few, has been brought within the capacity of the larger number, who were a long time content to serve as purveyors to their betters. It is not so many years ago that in a city so large as New York a half score of surgeons were intrusted with practically all the more important surgical procedures. The array of physicians and gynecologists of corresponding positent to serve as purveyors to their betters. It is not gical societies bear witness to the learning, skill, and capacity of the host of younger men who now maintain a rightful place in the foremost rank of their elders.

The causes of the wider and more general professional activity are not difficult to find. In this, as in the inclination to minute and laborious investigation in the pursuit of facts which may be utilized in the attainment of material advantage, we but reflect a general tendency of society at large. The process of intellectual fermentation characteristic of the time permeates every stratum in every subdivision of the social organization. The nature of the work which in the progress of events has fallen to the lot of the present epoch favors its ample distribution. The qualities of mind which it demands are those which are largely developed in an era of advanced civilization. Patience, industry, perseverance, the faculty of close observation, the power of careful analysis and comparison, the subordination of the imaginative to the logical faculties, are made common in a learned profession by heritage and education, and are adequate to medical inquiry upon its present lines.

It is not a matter of reproach that these qualities give to mediocrity its opportunity. Men of genius have quite too long obscured the modest achievements of their fellows, and have too often hidden the march of men, perchance of somewhat smaller stature. The mas