\ James it. manley'S ANNIVERSARY DISCOURSE, 184$. f ' *■<■£. tV. 2i'S ANNIVERSARY DISCOURSE, BEFORE THE NEW-YORK ACADEMY OF MEDICINE, NOVEMBER 8th, 1848. * t BY JAMES E. MANLEY, M. D PUBLISHED BY ORDER OF THE ACADEMY. -:;iU*s ■■•-* % NEW-YOlK: H. LUDWIG & CO., PRINTERS, 70 VESEY STREET 1849. DISCOURSE. Gentlemen: Fellows of the Academy of Medicine—I have not the privilege of opening my address this evening in the usual manner, by apologizing for my appearance; by deprecating your criticism, or by a labored at- tempt to forestall your favorable opinions. I have barred myself these rights, by accepting the station to which I have been elected without any conditions. This appointment of Orator of the Academy, which is highly complimentary, is not the less valued be- cause it was unexpected and unsolicited; but if I could be indifferent to the manner of discharging the duty, I should be unworthy of the honor; it is not necessary for me, therefore, to say that I gratefully acknowledge the obligation which your partiality has imposed. I am not without apprehension, however, that some of the opinions which I may advance will not meet with the hearty concurrence of all whom I address, since interest is often found to conflict with duty so much, as to warp the judgment even of those who aim to discharge it most conscientiously. Being pretty confident that I should meet a mixed audience, I have chosen a subject which is at this time one of absorbing interest, equally affecting the public and ourselves; and the public will probably 4 DISCOURSE. receive the largest part of my attention. I shall speak of the abuses of medicine, in connection with the education of physicians, with a view to their cor- rection. Perhaps there never was a time when medi- cal abuses were more rife, medical impostures more successful, or medical delusions more fatuous or more fatal; and it is as much our interest as it is our duty, to inquire into their causes, that we may take all Reasonable measures which the nature of the subject may suggest, to limit their influence. With this short preface, and with your permission, I will proceed: " There is a way that seemeth right to a man, but the end thereof are the ways of death."—The audience need not feel alarmed, or anticipate that I intend to deliver a moral lecture, or descant on the casualties which attend all human cal- culations. I have a different object in view ; and in place of discoursing of chances, accidents and neces- sary evils which no human intelligence can foresee, or if it could foresee, could avoid; I purpose an attempt to show that much, very much of the distress, the dis- ease and bereavements which are usually considered inevitable, are justly chargeable to a want of that in- formation which it is in the power of every person in an enlightened community to possess, if he would be at the pains to acquire it; and I design also to show. that so far from having an apology for arraigning the allotments of God's providence; the casualties of dis- ease, the consequences which result from them, and even Death itself, to which, by the very law of Life, DISCOURSE. 5 all must submit; are, nevertheless, so far as concerns the amount of the one, and the period of the other, measurably within the control of human skill, under the guidance of an enlightened reason. That an enlightened reason does not direct in all cases, re- quires no evidence; that in many, no reason at all can be assigned for the conduct of circumstances whose issues are irreparable, is just as obvious : and it is my intention to open up some of the causes which have contributed to this unblessed result. There are not, neither can there be, any questions more interesting than those which have as objects of inquiry, the preservation of health, the security of life when threatened by disease, or its continuance under circumstances of comparative comfort, when the hope of complete restoration has been abandoned; and yet, strange as it may appear, those are precisely the subjects to which the least attention is directed. Although, in the emphatic language of the Bible, " All a man has will he give for his life" he does not even trouble himself to inquire into the proba- bilities of success which may attend the means directed either to preserve his health or to protract his existence. It would seem that, in the words of the poet, " All men think all men mortal but themselves:" that in- telligence, however well directed in all minor concerns, in times of disease, whether aggravated or otherwise, loses all its power to control the conduct; and that which of all possessions is held most valuable, is fre- quently abandoned to the chances which the stupid 6 DISCOURSE. doctrines of fatality could only suggest, or which in effect is the same thing, transferred to the keeping of persons alike ignorant of their duty and its respon- sibilities. This language may seem much too strong to be digested by those who have, during all their lives, been the willing victims of delusion and imposture, for no person feels flattered when convicted of folly ; but the simplest illustration will confirm its truth : e. g., Intermittent fever and Consumption are two of the most common diseases; the one is considered a matter of small account, whilst the very name of the other terrifies almost as much as apoplexy; in both cases, it is easy to show that opinion is wrong, and in some instances, fatally wrong. Intermittent fever is not the very trifling disease which many persons believe ; nor is consumption so fatal as those who are threatened with it apprehend ; there is one form of it, it is true, for which little can be done with a prospect of permanent restoration to health; but that form is much more rare than the majority of the public believe. Suppurative tubercular consumption of the lungs, we think, is one of the opprobria of med- icine, although, even in that form, much may be done to protract the term of human life, and render exist- ence not only tolerable, but desirable. A vast ma- jority of fatal cases of consumption, so called, (often very improperly,) are made such by the patients themselves, or by their misplaced confidence in the advice of officious but ignorant friends. Much of its mortality is justly chargeable to the mistaken treat- DISCOURSE. ment of previous maladies, which have no necessary connection with consumption, although they may be converted into its causes, without the patient being made sensible of the transition, until it is too late to apply the remedies. The cases of idiopathic con- sumption, it must be allowed, are numerous ; but, fre- quent as they are, they bear no assignable propor- tion to those which are secondary and consecutive. The disease called intermittent fever, on the other hand, although, as such, it is attended with little ap- prehension, and in this climate, no fatality, is one of the most prolific sources of chronic diseases known to physicians. In general, it is treated by domestic remedies, almost always empirically, and sometimes not treated at all; the patients in the interior of the country especially, trusting that time, a good consti- tution, and change of season, will bring with them all the benefits which could be derived from the best medical attention; and the consequence often is, that while they flatter themselves with the idea that they are restored to health, they have only changed one disease for another infinitely more difficult of cure, and positively dangerous in its results. The differ- ence between a cure and a transmutation of disease, is frequently the difference between health and death; the last a little time deferred, it is true, but not the less certain, inasmuch as the new disease is almost always one involving morbid structure of the organs on which the previous complaint has spent its strength, and such condition forbids the indulgence of the hope of permanent amendment: the sufferer, thus circum- 8 DISCOURSE. i stanced, has nothing to expect but a protracted ill- ness, which works its own cure, not by a restoration to health, but by reconciling the subject to its ulti- mate consequence, death ! If we can succeed in assigning this misplaced con- fidence, or apparent indifference to its proper causes, we may be enabled to prescribe for its cure, or in my event, present some means which, if followed out, will (if they cannot rectify) have a tendency to moderate or control its influence. The time has been, when in inedicine, belief was founded on testimony, and when the measure of con- fidence accorded was in proportion to the evidence presented; but it would seem that this period has passed by. Medical opinions are now promulgated, received and practised upon, which rest on nothing which the intellect can grasp or the senses can detect; and the public are required not only to con- fide without testimony, but in defiance of it. Medi- cal follies have become so fashionable, that we are under the necessity of using serious arguments to op- pose glaring absurdities, which one would think could not impose upon the consciousness of a child; and so contagious has this fatuity become, and so numer- ous are its victims, that the infection of disease in its aggravated condition of an epidemic cannot compare with it in fatality. Between the rivalries of bold im- posture, presuming ignorance, and calculating deceit, the great and essential landmarks which have hitherto directed to the best means for the preservation of health, and the relief or cure of disease, are in danger DISCOURSE. 9 (for a time at least) of being broken down and trampled under foot of men, whose contempt of every- thing like a medical education is their surest pass- port to the confidence of their patients. It is scarcely to be expected that the medical pro- fession, alone and unaided by public opinion, can correct the abuses to which its own lax estimate of its duties have chiefly contributed; but the hope may be indulged, that a reform commenced among its own members will not be without its influence in enabling the community to form a judgment of the immeasur- able difference between a well-instructed and consci- entious physician, and the ignorant, impudent and reckless practitioner, who monopolizes the confidence and the emoluments of our vocation. Reform must commence where the abuses have had their origin, since it would be vain to expect amendment while the roots from which they spring are allowed, year by year, to gather strength, to bud, blossom, and diffuse their baleful influences. The standard of education in medicine must be elevated; then, and not till then will physicians be enabled to resume that rank in society which they formerly occupied. The moral tone of the profession must become a subject of more solicitude. When I speak of morals, I do not intend by them the con- ventional code of expedient ethics, which are altered by circumstances, and limited in their influence by lines of longitude and latitude, or the fashion of the day; but I wish to be understood as speaking of the morals of the Bible; essential truth must be the basis 10 DISCOURSE. of a physician's moral, for that is Heaven's criterion v of character.—" They are my people, children who will not lie" saith the book. Elementary education, also, which alone can give promise that the pupil can make profitable progress in medicine, must be made an indispensable condition to his entrance upon its study: I do not now speak as the advocate of the medical profession only, but as the ad- vocate of humanity; as the advocate of common sense. I do believe that the recorded and traditionary expe- rience of five thousand years, are safer depositories of the public confidence, and more reliable guides to the successful treatment of diseases, than the crude dogmas of erratic, morbid or depraved intellects, which cannot boast the merit of conviction even of their own supporters. I speak as an advocate un- feed and unsolicited, and therefore have no apology to offer, except it be the importance of the subject. There are occasions, even although personal interest would appear to counsel a different course, when inclination is constrained to wait on duty, and when no timid calculation of apprehended conse- quences ought to be permitted to repress its honest and conscientious discharge ; and the present, in my view, is one of them. I know that it may be objected, that the subjects of popular delusion are too numerous, and their causes for the most part too obvious, to require a serious examination; that many of them have the character of ephemeral follies, which the slightest exposure is sufficient to dissipate, because the great DISCOURSE. 11 mass of the public have no interest in perpetuating them ; but this is a great mistake. It is to the indif- ference manifested by the profession to the inroads of ignorance and deceit, that we have a right to at- tribute a large measure of their success ; for it is not to be expected that the public will interest themselves to prevent their extension, when those to whom, in an especial manner, is committed the keeping of the interests and honor of the medical character, appear to acquiesce in the degradation of both. But if it were true of some, it is not true of all; there are some which affect to clothe themselves in the garb of Philosophy, and which offer to teach great truths in natural science which have hitherto remained un- revealed, and Medicine is the great field chosen for their exhibition. That profession which most espe- cially calls into active exercise all the powers of the most cultivated and vigorous intellect, all the kindly affections of the most benevolent feeling, and all the awful responsibilities which bind man to his Creator, is permitted to be perverted to the practice of a trade for mere emolument; when common sense being the judge, by the very necessity of the case, as such it must be a trade in blood. It is a humiliating consideration, one calculated to damp the ardor and paralyze the exertions of the most intelligent and comprehensible benevolence, that health, disease and death, and the priceless conse- quences with which they are allied, are treated by the public as matters of infinitely less consequence than the ordinary concerns of business life; and that the 12 DISCOURSE. bounties which are awarded to medical men, are for the most part accorded to those whose only wisdom is cunning, and whose only moral is selfislmess. Medical delusions differ from all other deceits, be- cause their consequences are visited by penalties which cannot be remitted. There is no court of ap- peal to correct the errors of quackery: the unhappy victim may be made sensible of his folly, and willing to submit to the laws of necessity, and die when, in the language of the multitude, " his time has come." But who does not know that the exhibition of poisons will expedite the event ? who does not know that the prescription of palliatives will waste time, and allow disease to ravage during the precious period which should be improved for recovery ? and who does not know that for time so wasted nothing can compen- sate ? And yet, in defiance of the experience which every day, nay, every hour presents, ignorance and imposture, aided by a knowledge of human weakness which knows how to flatter, although it cannot rea- son, is permitted to batten on human suffering, and make merchandise of human hope. Medical delusions, unlike all others, spring up in soils where nothing else will grow, and where nothing else could reasonably be expected; they address themselves to the fears and the hopes of the ignorant multitude, who do not reason, or if they do, it is under the controlling influence of one or other of those passions which will not admit the exercise of an un- biassed judgment; and it is on this last principle alone, that we can furnish an explanation of the sur- DISCOURSE. 18 prising fact, that men of education are so frequently found among the number of their victims. The love of life, and the painful anxiety which attends all aggravated forms of disease which do not impair the functions of the brain, would lead us to believe that all the powers of the mind would be called into ac- tive exercise to provide against the contingency which men most fear; but it is not so,—in time of utmost need, that moral balance which controls the conduct in all other concerns appears to be de- stroyed ; and the understanding, which in a time of health and strength could direct the destinies of an empire, and furnish expedients in difficulties which threaten the most disastrous consequences, is found crouching to the knave, whose vocation it is to make merchandise of its weakness. It cannot be for a moment supposed that any person of sound mind can be indifferent to that event which separates him from everything which binds him to existence : he who can contemplate without emotion the end of his mortal being, must be either idiot or insane, for the only exception which exists, cannot apply to either. The transition from a well-spent life to a happier and more enduring existence is that exception, and it is right that it should be. The law of our being binds us to life, and nothing but a law stronger than it, will ever reconcile a sane man to the separation. The conviction that all must die, has no agency in this matter: for notwithstanding this conviction, every person is intent upon the means which he believes 14 DISCOURSE. best calculated to ensure his recovery, or to defer the event to its utmost limit. That these means are frequently mistaken, is not doubted; that the mistakes occur like most other mistakes in life, from a want of capacity to balance evidence through the influence of passion or affection, which respond to no rule of action but impulse, is too true to admit a question; but that persons should fall into mistakes which involve the issues of life and death; the one the greatest blessing and the other, humanly speaking, the greatest curse; with more facility and apparent indifference to the conse- quences than usually attend the most trifling incidents of every-day life, is a paradox which no human in- genuity can satisfactorily solve; and the mind, in contemplating the marvelous anomaly, is constrained to give up the explanation, cast itself on the doc- trine of fatality, and refer all the difficulty to an agen- cy which takes no counsel of humanity, but does what seemeth good in its own righteous sovereignty. In intertropical climates, and in countries where pes- tilence is native ; where disease floats upon the breeze which for a while seems to invigorate ; where poverty, oppression and destitution have made the term of hu- man life scarcely worth a day's purchase ; and famili- arity with the image of death has well nigh oblite- rated the love of life as an instinct of being; facts like these could find a ready solution : but that in civilized society, where the attachment to life has not only the strength of a natural law, but all the addi- tional supports to be derived from its intelligent enjoy- DISCOURSE. 15 ment; where, as if to render the fact still more astonishing, the desire to live is superadded to the law of natural necessity, the same result.should fol- low ; is a truth almost too incredible for the most expansive faith, and could not be believed were it not for its constant recurrence. That causes so dif- ferent should operate the same result; that the tedi- um of life, under its most afflictive circumstances, should be scarcely less efficient in reconciling man to his mortality, than the intense and ardent desire to escape it, should be in expediting and inviting its advent; seems to involve an absurdity which defies all reasoning: and yet such are the facts presented to our every-day observation. We are, however, not left without some data to ex- plain this apparent paradox. It seems to belong to our very nature to deceive ourselves, for reason is powerless where our passions or our sympathies have the control of our conduct; and that such is our condition, when enervated by disease, none can doubt. He who is suffering from a painful malady, or apprehensive of its fatal issue, will almost by in- stinct give his confidence to those who will promise most, without attempting to balance the evidence on which such promise is made ; his fears and his hopes both combine to deprive him of the exercise of his judgment, and to make him the willing victim of im- pudent imposture or presuming ignorance; for pa- tients, therefore, there is some apology : and we are more disposed to pity than to condemn. But what apology can be offered for those who make capital of 16 DISCOURSE. human frailty ? How can their conduct be made to consist with the eternal rule of right, which without the intervention of law, teaches the untutored savage to do to others as he would that others should do to him ? Who, under the guidance of mere natural conscience, we may ask, would make merchandise of human suffering, and batten on the proceeds of deceit practised at the risk of human life ? The prompt response is, none ! no, not one. But ordina- ry observation teaches a different lesson. There are multitudes of men calling themselves physicians in our midst; men claiming to be respectable, and whom the world does respect, whose support is pro- cured, and whose wealth is accumulated, at the ex- pense of the health and the comfort, nay, the lives of those who confide in their fraudulent professions; professions too, not made under the influence of self- delusion, for in such cases our charity could in some measure qualify the severity of our judgment, but made for the sole purpose of profiting by hopes based upon them, which they well know will be disap- pointed. This pestilent evil, which " walketh in dark- ness and wasteth at noon-day," which creates confidence merely to serve as capital, reckless of con- sequence, has become in truth a wide-wasting epi- demic, so destructive in its course, that the question whether medicine has been a blessing or a curse to our race, has been seriously mooted by intelligent men who profess great confidence in its resources ; because it has served and does serve as the pretext for all the wickedness done under its name ; and the y DISCOURSE. 17 speaker, although a physician from early manhood, is more than half inclined to believe that the benefits derived from its intelligent and conscientious exer- cise, do no more than compensate for the mischief done with its apparent sanction ; and if there be no means within our reach to arrest the progress of the delusion which furnishes the victims whom deceit and ignorance daily sacrifice at the shrine of mam- mon, he will be constrained by the weight of evidence to conclude, not only that there is just reason for the doubt which suggested the question, but much rea- son to fear that the doubt will give place to certainty. It would be but labor lost, to attempt to cure the evil by remonstrating with those who have a personal interest in perpetuating it: the facilities which medi- cine offers to practise imposture, and the bounties paid by an unconscious public for the deceit, are ob- stacles in the way of all argument which truth can present, because mistaken interest is enlisted on the side of fraud. The evil is too deeply rooted, to per- mit us to indulge the hope that it can be effectually eradicated; but if it cannot, much may be done to prevent the extension of the fatal epidemic. We may excise some of the roots from which it derives support, and we may render it odious and contempti- ble to the moral sense of the community, by exhibit- ing it as an offence which cannot, in the judgment of the most generous charity, admit of palliation. But to do this, we must commence by communicating to the public, who are the victims of the delusion, some knowledge of themselves; we must attack 2 18 DISCOURSE. their prejudices by informing their minds, and teach them, all that it is necessary that they should know; the great principles on which the science of all rational medicine rests. It is in this way, and in this way only, that common-sense will ever procure a hearing from the infatuated multitude ; and it is a marvel that they should require to be so advised, when their most impor- tant interests counsel the same course, without instruc- tion. We take unwearied pains to educate our children : we teach them, or endeavor to teach them, the laws which govern the universe ; all the science known under the name of natural philosophy, as well as the laws which control, without their conscious agency, the operations of their own minds; we endeav- or, by inculcating a knowledge of men and things, to qualify them to become active, efficient and useful members of society, because we believe that such education is essential: and yet we are content to leave them as ignorant of themselves, their structure, their organization, and the various functions resulting from that organization, as if all such information was superfluous and unnecessary. Is not such a course of preparatory instruction, however extensive, radi- cally defective ? The answer, on the least reflection, must be affirmative; and although we are frequently forced to consider this deficiency, it is only to regret it, since in a large majority of instances it does not admit a remedy. The deluded victim of quackery may before death become sensible of his folly, but when it is too late to repair its consequences. It would seem that the necessity of engrafting DISCOURSE. 19 human physiology in our courses of general academic instruction, was not only important, but imperative; as it would serve the double purpose of a protection against the assaults of quackery, and furnish that kind of intelligence which would enable the public to form a more accurate judgment of the character of their physicians. I am very sensible that this is considered, by many of the profession, as a recommendation of doubtful expediency ; but I confess that I am yet to learn that it differs in principle from the constantly iterated opinions given to the community on the subjects of public hygeine or medical police, which all deem matters of professional duty. It is certainly a matter of common observation, that age, experience, educa- tion, intelligence, probity, courtesy, and the most disinterested benevolence exercised by physicians, are all utterly powerless to arrest the march of impos- ture and delusion ; nay, that so far from exerting any preventive influence, physicians increase the evils by attempts to expose them: and if such be the fact, what alternative can be presented other than the one here suggested ? If men will not take counsel of their own experience, to what school shall they be addressed ? I am impressed by the belief while I am speaking, that the opinion given will be neglected, not because it is unsound or unsafe, but because more persons are interested in perpetuating the mis- chief, than there are influenced by conscience and duty to expose and destroy it. It will be found to commend itself, notwithstand- 20 DISCOURSE. ing ; for the great mass of the public are, even now, reaping the fruits of the folly manifested in their utter disregard of it. The histories of disease and death within the circumscribed limits of one's own ac- quaintance, is appalling, and calculated to teach les- sons which, in our judgment, could never fail of their effect, or be forgotten. We every day see the most simple and manageable complaints, which, but for the interference of nostrum-mongers and pretenders, (who with or without warrant call themselves physicians,) would, with very little well-directed medical atten- tion, leave the patients in as good health as before the attacks; become serious causes of lasting mis- chief to their constitutions, terminating not only in diseased function, but in organic lesions, which point with unerring certainty to fatal issues: (for the dif- ference between curable and incurable disease con- sists essentially in this—in the one class, function only may be deranged or impaired ; in the other, the structure of the organ is destroyed: in the one, healthy action may be restored; while in the other, no room is left for the indulgence of such an antici- pation.) There is, however, no morbid condition of the human system which can in strictness, be considered simple, and the least knowledge of physiology must make it obvious : the danger, therefore, is infinitely enhanced by attempts to prescribe for single symp- toms, without reference to the necessary connection which those symptoms have with others, which by DISCOURSE. 21 natural consequence must succeed them.* Every symptom pertaining to a disease stands in the rela- tion of cause and effect: the first is the cause of the second, the third the result of the two preceding, and each succeeding one which marks the course of the malady is the result of the combined morbid action of those which went before it; and it is sim- ply impossible that it should be otherwise. That which renders the danger still more imminent, is, that their succession is so rapid, especially in cases accompanied by fever, that constant attention is necessary to obviate or anticipate their advent. How often do we find even intermittent fever, which by the way is the simplest form in which febrile disease is manifested in temperate latitudes, from this cause alone degenerating into local diseases of important * Homoeopathy prescribes for sensations, and not for symptoms, and the remedies are assorted according to the sensations which they pro- duce ; so that the symptoms of the medicine, and not the symptoms of disease, guide the practitioners in their treatment! Of all the follies which have ever taken possession of a deluded public, not even excepting that of prescribing for patients without inquiry into the nature of their diseases, this pseudo philosophy called Homoeopathy is entitled to the palm It sets at nought all the laws of Nature ; it claims that medicinal agents are remedial in an inverse proportion to the quantities exhibited ; that is to say, that an ounce, a dram, or a grain, being remedial,—the ten thousandth, the millionth, billionth, or decillionth part, is much more effective ; so that the premises on which the system is founded being granted, all medicine consists in negation: for the doses prescribed are infinitely less than are exhibited day by day in our food and drink, for the sustenance of the human body in a state of health. And yet this is a doctrine to which common sense is called to subscribe, in opposition to the accumulated experience of nearly six thousand years, which is the groundwork of all rational practice in medicine ! 22 DISCOURSE. organs, partial effusions or general dropsies ? The experience of every well-informed physician will fur- nish abundant evidence, that facts like this are very common; and the true reason is, that the original complaint, be that what it might, had been viewed as a matter of small consideration ; altogether overlook- ed ; or treated without reference to that most con- stant law of all morbid action, viz., its tendency to become complicated. To pursue this subject a little farther.—Of the great number of diseases to which we are liable, and to which medical science has appropriated different names, comparatively very few are simple in any sense, except for a short part of their course;. and besides, only a small part of them are idiopathic ;* a large majority are symptomatic or consequential, and derive their dangerous character from the ope- ration of causes, which, in most cases, are under the control of a rational treatment in their early stages. We have seen an intermittent transformed into a re- mittent, this again into a bilious remittent, and this last into a typhoid form of disease which did not admit of cure, because the system, or, we would rather say, the recuperative powers of it, had been exhausted by the mal-administration of medicines chosen without regard to this law of morbid action ; of which, no person claiming to be a well-instructed physician ought to be ignorant, and if informed, * The term, as here used, is intended to convey the idea of primary disease, having no necessary connection with any previous morbific agent, except as a cause. DISCOURSE. 23 could not be so deficient in his duty, as not to be anxious to anticipate. We have seen intermittent fever terminate in that most hopeless of all maladies, phthisis pulmonalis, or consumption of the lungs ; we have seen it terminate in chronic disease of the liver ^ of the spleen ; in a total derangement of the digestive organs; in tabes, in dropsy, and in death; with scarcely a symptom upon which to found a hope of recovery, from the period when the disease assumed a chronic character. If these facts, and facts of a similar kind, cannot be controverted; if mistaken means for recovery from diseases are more fatal than would be diseases without their use; what right has the great mass of the consumers of nostrums and patent medicines to calculate that the benefits ex- pected from them will compensate the risk which they incur, that they will but aggravate their com- plaints ? If no malady is simple, but all more or less complicated; if, besides, it is in evidence that scarcely any two diseases are precisely similar in character or curable by the same means, considered both in quality and amount, by reason of differences of constitution, or peculiar idiosyncrasies, or inten- sity and violence of attack; can it be matter of sur- prise that their general and indiscriminate use should swell the bills of mortality ? It is hardly credible, although it would not be difficult to prove, that the patronage of the public is accorded to quack medi- cines and their proprietors, in a ratio far exceeding that which the regularly-educated members of the profession receive ; and if common sense, in an at- 24 DISCOURSE. tempt to settle such statistics, should take into the account the numerous expedients to make money in the shape of new theories, such as Homoeopathy, Hydropathy, Mesmerism, Galvanism, Clairvoyance, Chronothermalism, and a multitude of other isms too numerous to mention, which are now extant; it would find, to its confusion, that its own name was a mis- nomer, and that common sense was a very uncom- mon article. This is too serious a subject to treat with any degree of levity, for the disastrous issues of those wicked experiments on the credulity of the public, prompt us so much to commiserate the sub- jects of them, that no room is left to treat it with ridicule: their folly is fatuity—their delusion mad- ness ! We need not attempt to disguise the fact, that the medical profession has of late years much deterio- rated : in the language of the late President* of the National Association, whose information on this sub- ject none will question, " it has become corrupt and degenerate, to the forfeiture of its social position, and with it, of the homage it formerly received spontaneously and universally ; and yet there is abundant evidence that the improvements in medical science in no pe- riod of the world, from the time of Hippocrates to this,day, have presented stronger claims to the public confidence. Let disease present in what form it will, it may always be' treated rationally, and in a vast ma- jority of cases, successfully, by the diligent practi- * Dr. Chapman. DISCOURSE. 25 tioner of medicine or surgery, who studies his art, and possesses sufficient information to improve by his own experience or profit by the experience of others. The misfortune is, that many of those who practise physic do not possess this requisite educa- tion ; they therefore do not grow wiser from obser- vation ; facts are abundant, but they are ignorant of the uses to which they may be applied; and their experience, in place of furnishing the means of im- provement in the treatment of disease, but confirms them in their errors. From a want of early instruc- tion in the knowledge of all the human functions in health, (physiology,) they cannot properly estimate the changes wrought by disease, and they become empirics from necessity ; for without this apology, their practice would have the character of wanton experiment. It is to this cause we are chiefly to at- tribute the loss of confidence which marks the con- duct of the intelligent portion of the community to- wards the profession. If physic is to be practised empirically, they claim to be as good judges of the effect of remedial agents, according to the measure of their experience, as those who make it a profes- sion, and' they become their own physicians, to their own harm. But besides this inducement, the public cannot fail to perceive, that this class of men almost exclusively are those who convert their profession into a trade ; and, having once imbibed this impres- sion, they extend it to the whole fraternity, and refuse to accord their confidence to persons who practise physic merely for its profit. As a trade, 26 DISCOURSE. medicine, in place of being a blessing, is a most comprehensive curse : it keeps the word of promise to the ear, but breaks it to the hope ; it infuses con- fidence by addressing alternately hopes and fears, utterly careless of the consequences, provided only that the results are profitable ; it studies the natural disposition of the sick man, much more than it does his physical constitution, or the character of his complaint; it at one time magnifies disease, in order to increase the merit of the cure,—and at another, conceals his danger, through fear that it should cre- ate alarm; and, in a word, it applies all the rules which custom has sanctioned in trade, to the most important and responsible vocation which can exer- cise the human intellect. To give a stone to him who cries for bread, is to add a cruel mockery to the refusal to relieve necessity ; and even the repro- bate in morals would resent it as an act of wanton wickedness, which would disgrace even his depravity; but to give perhaps a poison to him who asks for life; or be indifferent to, or careless of the result of the operation of a medicine, when peradventure all the interests of the recipient, both for this world and the next, may depend upon it; appears to be an offence which cannot be expressed in terms. The obliga- tions of duty cannot be made articles of merchan- dise : but that they are so made by all such as practise physic for the mere pecuniary profit which it yields, is so obviously true, that any attempt to demonstrate it would be in danger of being repudiated by the moral sense of my audience, as an insult to their un- DISCOURSE. 27 derstanding. While the medical profession addresses itself to interests which wealth cannot measure, men who address themselves to nothing else have been invited into it, and, after their admission, have de- graded it. There is perhaps in our profession a greater variety of character than in any other: it is a vocation in which every quality of head and heart can find employment, simply because there is no quality attaching to humanity which may not be di- rected by interest to its appropriate exercise. The cunning, the ignorant, and the presumptuous—the knaves from calculation—can find subjects in the simple by nature ; and the number of the credulous, the stolid, the prejudiced, the vain, the vicious, and the timid, offer abundant temptation for the display of all those varied arts which disgrace it, and render the science which ought to take rank by right as first in the catalogue of human benefits, last in the scale of public confidence. Our profession embraces a greater variety of character than any other, simply because every quality of head or heart can find em- ployment ; the weakness of our nature, even in its best condition, renders us liable to become the vic- tims of fraud, deceit, and delusion ; but, when ener- vated by disease, that liability is a thousand-fold increased, and those who practise their profession as a trade, know well how to turn them to a profitable account. We have said sufficient, in reason, to show that medicine, considered as a trade, is of all employments the most iniquitous. But there is still one view of it 28 DISCOURSE. which we may present, which adds to its unblessed consequences a double penalty. The fact that phy- sicians in many instances are believed to have aban- doned, in practice, the position that it is a high and sacred vocation, which ought to hold nothing in common with a trade, has infected the masses to such an extent; that every pretender to a remedy or new method of cure, who can by his manner impose upon the infirmity induced by disease, has their con- fidence in as much, or much greater proportion, than the most intelligent, educated, or scrupulous student of the science ; and a very natural consequence has resulted: the heart, the soul, the sympathizing in- terest which the physician (properly so called) is accustomed to infuse into his ministrations for the sick, is received as if it were but a trick of trade ; his solicitude is construed as a want of^onfidence in his art, and his most assiduous attention as an uncalled- for exhibition of anxiety, intended on]y to increase the measure of his services, to be paid at la"st in coin ! If such be the fact, what may be expected to be its results ? Why—that it will react on the morals of the profession itself, for it is not in mere human nature to compromise such insults. One individual may be thought to have defrauded another, may in- sult his understanding, or may offend his pride, but yet abundant room may be left to repair the offence, when passion shall have given place to reason, be- cause, where mistake or misapprehension can possi- bly occur, both may be in fault: but when insult is offered to feeling; when goodwill is thrown away, DISCOURSE. 29 or, what is still worse, when its kindliest expressions are received wTith a cold acquiescence, or treated as the affectation of a sympathy feigned but not felt; the high-minded and honorable physician, from the very constitution of his being, is, as it were, con- strained to reciprocate the treatment he receives : his ministrations will be heartless, for his sympathies are rebuked and repudiated; and in the bitterness of his disappointment he will be tempted to compensate himself, by cherishing the exercise of a temper which shall be in exact correspondence with that which his patients manifest: he will in truth, by the mere force of a constraint which he has not the moral power successfully to resist, practise his profession as a trade ; and calculate the profits it will yield as the only compensation he will receive. And when a feel- ing such as this, which is with difficulty restrained by a sense of duty ; has supplanted the high and holy obligations which ought at all times to influence his conduct in the practice of his profession;—when his own personal and pecuniary interest is made para- mount to that which the sick have entrusted to his care and keeping;—what may we not expect ? In the language of the son of Hilkiah, (which I will quote with all reverence,) may we not exclaim with a mixed feeling of indignation and of pity, " What will ye do in th$ end thereof?" We are unwilling to believe that the practice of physic has with us been absolutely degraded to the condition of a trade, but we much fear that it soon will be : the preliminary information of the pupil; the 30 DISCOURSE. conduct of his medical education in some of our medical colleges; the measure of acquirement of the teachers themselves; their anxiety to profit by their situations, to which accident, management, or the influence of political friends have promoted them; and the known fact that volubility of delivery, a fund of anecdote to amuse, rather than a store of scientific intelligence upon which to draw for the instruction of the students, and a cultivated familiarity with them, which in effect defeats all proper discipline, and destroys all the deferential respect which should attach to the character of instructors ; and above all, the indefinite multiplication of the schools, contribute infinitely more to make it such than all other causes combined. Lecturing, itself, has become a trade, confessedly such, practised more for its profits than for any other purpose; and Professors, like Thespian players, travel around the country, for the amusement as well as the instruction of their hearers, till they may find a field of promise where their peregrinations may terminate, and themselves become stationary teachers! If these things are so, can it be matter of surprise if their pupils should " better their instruc- tion, " and become tradesmen too ? It is a fact, and one too pregnant with disastrous consequences to pass without the unqualified censure of the whole profession; that some of our medical schools, in their annual circulars, invite, nay, almost entreat the public for their patronage ; they present inducements to the half-educated, and even the wholly uneducated youth of the country, to become DISCOURSE. 31 physicians, promising facilities for study and full courses of instruction on easy terms; and on their arrival, accept promises to pay at remote periods in- stead of their fees; thus offering bounties to the igno- rant and illiterate, to crowd the ranks of a profes- sion whose duties and responsibilities require higher attainments, a more elevated moral, greater industry, and a more severe and constant application to study„ than any other profession in the whole catalogue of human sciences. Is it possible, under such conditions as these, that physicians pan acquire or maintain a character for talents, integrity and disinterestedness, all which ought to be essential to secure the public confidence ? The time has arrived when medical schools must become subjects of discipline: enlightened public and professional opinion has settled itself with re- spect of the causes which have and do operate to convert medicine into a trade. Professional men see with concern that its character, as well as themselves, are doomed alike, the one to disgrace and the other to ruin, unless some measures be adopted to restrict the wholesale issue of physicians, which year by year are furnished by the schools, which appear, by their acts, to acknowledge no rule but interest. It is one of the remarkable features in the history of legisla- tion in almost all the states of this great confederacy, that all interests of every kind have the protection of the laws, those pertaining to medicine only excepted. These are left without any defences; every man may practise physic, if he please, subject only to 32 DISCOURSE. the restraints which the common law imposes; but to obtain the public confidence, it is necessary that he should be armed with some testimonials of his ability to assume its duties, and this would seem to be the only use of diplomas. The great mass of the public are not judges of medical acquirement, and therefore their necessity. All medical schools do issue them, upon a compliance with the rules which they think proper to adopt; and they have the right, seeing that they are merely certificates, al- though they serve as licenses. Now it is in evidence that some of those schools have not the appliances necessary to the proper education of the physician : the courses of tuition are too short; the branches taught, as well as the number of teachers, too few, even allowing them to be properly qualified for their duties; and the facilities for acquiring a full know- ledge of their profession, too limited to permit us to indulge the belief that the pupils can be properly in- structed. " Those who think long upon a subject, usually attain to think right." The educated portion of the medical profession have thought long on this subject, and with a unanimity which challenges universal confidence, they attribute most of the abuses which are now extant, to the causes above enumerated. At no time inrthe history of our science, have we had more reason to congratulate ourselves on the measure of its progress: medicinal agents of extra- ordinary power, for good or for evil, have been dis- covered and applied for the relief of suffering hu- DISCOURSE. 33 manity; and it depends upon the measure of intelli- gence which directs their exhibition, whether it shall be the one or the other. If medical education be neglected, nay, if it be not much improved, they will be as edged tools in the hands of children : in place of being remedial, they will prove destructive ; and, since medicine was first taught as a science, there never was a greater necessity for thorough instruc- tion. The two reports made to the National Convention which met in Philadelphia in May, 1847, the one on the subject of the requirements for the degree of Doctor of Medicine, and the other on the prelimi- nary education of the student, are replete with infor- mation, not only of serious, but painful interest. From those reports it would appear, that nearly 1300 persons were graduated in the various schools of the country in the year 1846; that in 19 schools, (which were all which reported their condition, although 33 were addressed,) 730 pupils were graduated, of whom 581 had not the benefits of dissection; 403 had never received clinical instruction ; and that preliminary education in none of these schools was made a pre-requisite for admission ! In what man- ner, or by whom, the examinations were conducted, does not appear; it is probable, however, that the examinations of the whole number, 1300, were made by those who were their instructors, because it is a right which the professors do not incline to relinquish, although it would be easy to show that their own interests and the characters of the schools which they 3 34 DISCOURSE. control, would be promoted by such a measure. We have no means of ascertaining the actual number of persons who were admitted to the degree of Doctor in the years 1847 and 1848; it is presumed to be about 1500 in each year, as the additional number of medical schools, chartered or otherwise, would ap- pear to warrant such a conclusion. The reports further state, that it is computed that we have at least in this country, (United States,) " 40,000 men authorized to practise medicine and surgery, which allows a ratio of one to every five hundred inhabit- ants ; and if we add (I quote the report) to this 40,000, the long list of irregular practitioners who swarm like locusts in every part of the country, the proportion of patients will be still more reduced.'' u No wonder, then, that the profession of medicine has measurably ceased to occupy the elevated posi- tion which once it did; no wonder that the merest pittance in the way of remuneration is scantily doled out, even to the most industrious in our ranks; and no wonder that the intention, at one time correct and honest, will occasionally succumb to the crav- ings of a hard necessity. The evil must be corrected. With a government like ours, to diminish the num- ber of medical schools is not to be expected, and the corrective can alone be found in the adoption of a standard of requirement which will place the di- ploma beyond the reach of those who would wear its honors without deserving them." It is an axiom in political economy, that when an employment1 presses on its own support, it presses DISCOURSE, 35 also upon its moral: it is undoubtedly true of all other occupations in life, and the practice of medicine will not be claimed as an exception. Indeed, we have the evidence of its truth, if we turn attention which way we may. It is undoubtedly true of the profession of the Law, and is becoming more and more apparent every day in our own. The multiplication of medi- cal colleges, the slender measure of instruction which they can afford, and the cheap rate at which their honors are disposed of, all combine to crowd the ranks of the profession to such an extent, that the means of honest support are insufficient for its com- fortable maintenance. The educated part of the profession, who are proud of their acquirement and jealous of their honor, have long seen this evil, but they now feel it. The supply of physicians so far exceeds the demand, that the emoluments of their vocation in some parts of our country scarcely exceed the wages of the day labor- er: their necessities press like those of Shakspeare's apothecary: their morals are not strong enough to resist starvation, and they are tempted to put them in market to procure their bread. I have trespassed so long on your patience, that I feel it necessary, as well on your account as on my own, to hasten to a close. The subject can never be without its interest while the abuses exist; and that they will continue so long as private speculation in teaching controls the issue of medical licenses, is too probable. The time was, when the schools of medi- cine gave character to the profession, but that time 36 DISCOURSE. has long since passed by; it is now its chief anxie- ty to prevent the schools from destroying it. To educate a physician without any preliminary instruction in physics, mathematics, or the dead lan- guages, which alone will enable him to comprehend even the terms of the science ; and to assume that a medical education can be obtained in a shorter period of time than would be required to qualify an appren- tice for an ordinary mechanical employment; are positions which, we must confess, tax credulity to the utmost limit of its capacity, and are too monstrous and absurd to be for a moment entertained. It is painful to contemplate, that the well educated and enlightened portion of the medical profession have nothing to oppose to this inconsistent and destructive policy: the purity of their own motives, the con- sciousness of their acquirement, and the deep sense of the responsibility which attaches to their vocation, are the defences upon which alone they must rely for the support and confidence of the public, until these pestilent evils work out their own remedies.