^m^^mmm 4 /, A4^i $c*/Aa*t t\\xi\ fMraism, fr ADDRESS BEFORE THE PHILADELPHIA COUNTY MEDICAL SOCIETY, >* DELIVERED FEBRUARY 24, 1859. BY JOHN BELL, M. D AT THE CLOSE OF HIS OFFICIAL TERM AS PRESIDENT. PUBLISHED BY ORDER OF THE SOCIETY. PHILADELPHIA: COLLINS, PRINTER, 705 JAYNE STREET. 1859. . , v/A \\ eMtal fhtfliura. ADDRESS BEFORE THE PHILADELPHIA COUNTY MEDICAL SOCIETY, DELIVERED FEBRUARY 24, 1859. JOHN BELL, M. D., AT THE CLOSE OF HIS OFFICIAL TERM AS PRESIDENT. PUBLISHED BY ORDER OF THE SOCIETY. • > philTFelphiaT COLLINS, PRINTER, 705 JAYNE STREET. 1859. # ■ ADDRESS. Our Society requires that its President shall deliver a public address at the close of his term of office. He is, of course, free to select bis subject. It may be treated in a strain of advice or of encouragement, of warning, or even of reprehension; provided, always, that it be clothed in the language of sincerity and good- will. The science, the art, the literature, and the ethics of medi- cine, furnish numerous themes for copious and learned, and even eloquent discourse. It has fallen to my lot, during a tolerably long and not idle life, to glean something from the various fields in our professional domain; and I might, perhaps, without pre- sumption, make an offering to you, at this time, of some of these gatherings. But why should I attempt to indoctrinate those who are, as their title implies, already docti, learned men; or to pene- trate into the mysteries of science, and to portray its diversified aspects and relations to those who, with microscope armed, can see through and through an object, and enjoy the additional privilege of afterwards reasoning round and round about it? Who shall say where the homologous ends and the heterologous begins? Some histologists are now inclined to question the correctness of the sentence of outlawry pressed against certain diseased textures, just as some historians would plead an arrest of judgment on cer- tain personages who have always been spoken and written of in terms of execration. We are told, for example, that the terrible cancer itself, which but yesterday, as it were, was declared to dis- play its virulence, not only on its face, but in its ultimate cells, is, to-day, alleged to have no such special characteristics, and that its cells are merely deformed homologous ones. So, in reference to some historical names—Tiberius, Richard III., and, just now, Henry VIII. We learn, as the result of more careful investiga- 4 tions, that these much abused gentlemen were full of good inten- tions, not, in truth, well understood, and which bad, somehow or another, gone astray. We are everywhere met by contrasts which, in the self-sufficiency of half-knowledge, we call contradictions. Bile and sugar are now found to keep company together, and even to be elaborated by the same organ, so that the old comparison— bitter as gall—must henceforth be qualified with the addition—but with a touch of the saccharine. It must have been by a psycho- logical analysis, conducted in a similar method, that the sweet part in the character of the tyrants just named has been discovered by their respective apologists. A history of the functions of the human organism would show almost as many changes and revolu- tionsas general history does of successions of dynasties and over- throws of empires; both of them having their mythical as well as their proper historic periods. Scarcely, for example, have we be- come accustomed to bear of pepsin and the part which it is assumed to perform in digestion, as well as that other, by which it is made to figure in the advertisements and placards of lying quacks, who cannot tell the difference between pepsin and pepper, when we are presented with pancreatin. Hitherto the pancreatic juice was be- lieved to be analogous to saliva, and to bold quite a subsidiary office in digestion. Now, through its active principle, pancreatin, it is invested with properties by which a common eater, who takes a dose of it, will be able to rival the gastronomic feats of a London alderman, or that more diminutive, but not less decided glutton, the hydra, which is all stomach. If the luxurious and degenerate Romans, under the empire, had known of the existence of this little polype and of its wonderful powers, they would have deified it, and placed its magnified image at the bead of their supper-tables. They endeavored to renew the pleasures of eating by takino- an emetic, and thus making room for a second repast immediately after the first. The hydra can, as you know, do this and more besides; not only can it disgorge itself of its prey, but, if turned inside out, as you would the finger of a glove, what was before skin becomes stomach, and is as eager for food and as ready to digest it, as was its legitimate predecessor, which is now metamor- phosed into skin. When we speak of changes and transference of attributes, our minds immediately turn to the nervous system, and especially to the spinal marrow and the great sympathetic, which, although it is 5 by no means a terra incognita, is still to physiologists what Central Africa has been to ethnologists and geographers—a wide field of discovery and no little speculation. For a while we were allowed to settle down into a belief in the conclusions reached by Sir Charles Bell and by Magendie, on the functions of the spinal mar- row; but we are all again at sea, watching the pilotings and sound- ings of men of another generation, who are as busy and industrious, and quite as confident of the truth of their views, as were their immediate predecessors. Progress, change, reform, and improvement are the watchwords of the day, saving and excepting always in as far as medical edu- cation is concerned. Our medical schools constitute no exception to the universal experience, that corporations never reform them- selves, are never the leaders, but always the opposers of innovation, which in their ears sounds like revolution and anarchy. Nearly a century has elapsed since the first medical school in the then British Provinces of North America was founded (1765), in the city of Philadelphia, by Dr. John Morgan and Dr. William Sbippen, with whom were associated, ere long, Dr. Adam Kuhn, Dr. Thomas Bond, Dr. Benjamin Rush, and, at later dates, Dr. James T. Hutch- inson, Dr. Samuel Powell Griffiths, Dr. Caspar Wistar, and Dr. Benj. Smith Barton, and in the early part of the present century (1805), Dr. Philip Syng Physick. During all this time the curri- culum of medical studies has undergone little change, and then not always for the better. There have been more curtailments of the original scheme of instruction than additions to it. The chair of clinical medicine, filled first by Dr. Bond, and afterwards by Dr. Rush, has, since then, been thrust to one side: that of natural his- tory and botany was never occupied except by Dr. Barton, before be was transferred to the chair of materia medica and botany. All the additions made to the first plan have been, not of branches, but of separate chairs for different branches, which used to be taught from one chair. The medical schools which, in succession, have been organized in different parts of the United States since the creation of that of the old Philadelphia College, afterwards merged into the University of Pennsylvania, have taken it as their model; and now, forsooth, in the entire length and breadth of the land, we are to content ourselves with a course of medical instruction, which, as measured by subjects or branches in the middle of the nineteenth century, was not deemed to be more than barely requisite to meet 6 the wants of the middle of the eighteenth. Branches of medicine which were then merely sketched have been filled up since to the extent of a hundred-fold, and new ones have been opened out; but still, no practical acknowledgment of the fact is made by a propor- tionately increased number of teachers, and scarcely any by an in- crease of the period in which they are to lecture. With a hundred- fold more positive facts pertaining to every branch of medicine, and a hundred-fold more experiments for their illustration and enforce- ment, the collegiate term allowed for the introduction and arrange- ment of these facts, and the making of these experiments, is, with a very few honorable exceptions, as brief as ever. The inference from this state of things is obvious. They who wish to obtain the full, or rather a liberal measure of medical attainments, must prose- cute their studies outside of college walls. Within these walls tbey cannot expect to receive methodical instruction in hygiene, public and private, botany, pathological anatomy, pathology in its large and recognized meaning, medical jurisprudence, medical biography, including the history of medicine; nor, finally, in medical biblio- graphy. As far as collegiate instruction goes, we are quite unpre- pared to appear before the courts of law, and to give our testimony clearly and with understanding on questions which affect the repu- tation, the fortunes, and the lives of our fellow citizens—questions which belong to medical jurisprudence, or legal medicine, as it is often termed. It would be thought strange for a politician, who aspires to figure in public life, to be ignorant of the history of his own country, or even of general history. What shall we say of the alumni of our medical schools being sent abroad into the world, in ignorance of the history of medicine, its successive improvements, and the causes which at different times retarded its progress, as well as of the distinctive merits of those eminent men who have enlarged the boundaries of medical science, or made improvements in medical art? It may be grating to our national vanity, which certainly is not small, for us to be told that, in the matter of medical education, Young America has yet much to learn from Old Europe; but, unfortunately for us, the averment is undoubtedly true. All honor and renown, then, to those noble men who forego the distinctions conferred by office and the emoluments from practice in the eager search after and discovery of new facts, and the deve- loping of accordant principles. They dig the gold, not always caring themselves to convert it into crowns for kings and current 7 coin for the people: tbey find the rich material for others to deco- rate themselves with. The world would bold of small account the common sense of those who, calling themselves utilitarians, should cry out to the patient delvers and miners of the precious metals: "We do not want your gold-dust or your lumps, or even ingots; give us something we can apply to purposes of use and ornament —vessels of various sizes and shapes, rings, brooches, clasps, chains, chased work, not to speak of plate for the table." The medical philosopher might ask: "Is there more wisdom in the cant of the day among many practitioners of medicine, who are continually calling for the practical, not as the crowning capital of the column of medical science, but rather, according to their notion, as a sepa- rate block, almost as rough as when taken from the quarry, but whose surface has been hacked by random strokes of common workmen, each leaving his mark, and calling it his experience." What long and patient delving into the interior of the human frame! What careful observation of the structure and connections of the several parts of which it is composed! What nice induction was exercised before an approach could be made to a knowledge of the uses and combined action of these several parts! Observa- tion, experiment, hypothesis, theory, were each invoked in turn before the meaning of what passes in the interior could be read on the surface, before the elaborated vital manifestations could be appreciated by and made serviceable to the practical physician. The practical man may be heard to boast that he contents him- self, in the treatment of disease, with noting the symptoms and prescribing the remedies which experience has shown to be most available for the removal of those symptoms. But, during this time, he seems to forget that he is not dealing with separate pheno- mena, ultimate facts, which have no special connection with or relation to one another, and require no chain of theory to unite them together. That of which the senses take direct cognizance is indeed a matter of fact, such as the color and coating of the tongue, the physical qualities of the pulse, &c; but the meaning, semeio- logically considered, of these appearances and states, is a question of theory, respecting which we cannot speak with certainty, inas- much as the precise relation between the phenomena observed and the state of the internal organs, of which the former are supposed to be the representation, the symptoms, in fine, is not equally demonstrable to the senses, is not a matter of simple legitimate 8 experience. A practical physician, so called, will say, that a yellow and loaded tongue indicates bilious disorder, and that such is his experience; that is to say, that he was taught this symptomatology, and continues to believe it. From this belief, he deduces bis prac- tice of giving a mercurial purgative. But, may not more careful observation show that all this so called experience, this alleged dealing in matter-of-fact, is false reasoning- is false theory; and that the stomach, not the liver, is in fault, and that a day's fasting, and the use of diluent drinks, may well be substituted for purging? There is not a single symptom to which a practitioner of medicine attaches any value that does not call on the intellect to trace in it a cause and an effect, and to deduce from this connection, be it real or be it supposititious, a new condition of things; in fine, a theory. How much more than theoretical, bow purely speculative must be that so-called experience which rests on conclusions from obvious phenomena, the inner or remoter causes of which are conjectured or unknown! Your mere practical man feels, for example, the pulse of bis patient, with a desire of ascertaining whether the latter has fever; and he thinks he is no theorist if, at the same time, be avoids all discussion or inquiry into the proximate cause and nature of fever. It does not occur to bim that in the very use of the term fever, he gives into an abstraction, and deals with a theory of the most complex kind. But waiving this point, he may, perhaps, assure us that the pulse, whose beats, and their force and regularity, or intermission, are matters of certainty, furnishes bim with most reliable indications of the intensity and the degree of the fever. He has no doubts on this bead; he confidently rests his belief on experience. But, to what does this experience amount ? It is neither more nor less than a repetition for a lengthened period of a theory, which supposes that certain physical characters of the pulse are caused by, or indicate those complex and unknown changes in the functions of the organ- ism, designated by the abstract term fever. During the long period of nineteen centuries, or from the time of Herophilus, of Alexandria, who was the first to speak of the arterial pulse, and of Praxagoras, who first gave it diagnostic value, down to the date of the discovery of the circulation of the blood by Harvey, physicians, practised ones, too, spoke and argued with confidence of the diagnostic and prognostic value of spbygmology, although they were long ignorant of the very first step in the real 9 process of causation—viz., the anatomical connection between the arteries and the heart, and that the pulsations of the former are the effect of the contractions of the latter organ acting on the con- tained blood while circulating in elastic vessels. Galen, coming four centuries later than Herophilus, taught that pulsations were caused by the vital forces, and that the heart, through the pneuma, communicated the pulsatile faculty to the arteries. He supposed tbe pulse to be an index to the vital forces, and, as such, that it pointed out, not only the character of the disease, but its probable termination, either in recovery or in death. He went farther, and invested tbe pulse with the function of preserving the animal beat, of drawing in cold air, and of discharging effete matters from the blood. Galen wrote a complete course of sphygmology, divided into four sections, each including four books, besides several mono- graphs on tbe same subject. In his first book, be enumerates more than sixty varieties of pulse, each having its distinct or diagnostic character, and indicating a particular disease. Hence, there was assumed to be a pleuritic pulse, a suppurative pulse, a phthisical pulse, an hepatic pulse, a splenic pulse, &c. In these refinements, the teacher of Pergamos has found imitators among the moderns, and especially among the French physicians of the last century. For the next fifteen hundred years, or almost until tbe discovery of the circulation of the blood, the Galenical doctrines of the pulse were taught in tbe schools, and received by practitioners of medi- cine as their guide in semeiotics. When Harvey appeared, and tbe true mechanical cause of the pulse was ascertained to be the contractile power of the heart and elasticity of the arteries, which last were no longer believed to contain vital spirits or air, in addi- tion to blood, the practical men of the day must have thought themselves aggrieved at a discovery which would require them to begin their experience anew, and to reach conclusions so different from those which had previously satisfied them. With the predominance of the iatro-mathematical school, and the explaining of the circulation of tbe blood and of other fluids of the living body by the laws of hydraulics, the pulse came to assume new and different significations from those that had been attached to it by the followers of Galen. Although called an eclectic, tbe eminent Boerhaave belonged to this school, and through his teach- ing, its doctrines, during a considerable part of the last century, were disseminated, and generally adopted throughout Europe and 10 in English America, as far as this country possessed at tbe time educated physicians. When, afterwards, by the labors of Stahl, Frederick Hoffman, and, above all, the lucid prelections of Cullen, vitalism, and with it solidism, obtained the ascendency, bow many wise doctors shook their heads, and readjusted their wigs, and planted their gold-headed canes on the floor with additional energy, while relating their experience in the Boerhaavian views of me- chanical obstruction and error loci, and of lentor and viscidity of tbe fluids as tbe cause of fever and inflammation! And the pulse—did not at all experience, they might be heard to exclaim, confirm the indications, in this sense, which it furnished? Boer- haave himself, repeating the language of Hippocrates, had said, experientia fallax ; and the fallacies of the great Professor of Leyden himself, furnished abundant evidence of the truth of the aphorism. There are other important phenomena in which the heart performs a conspicuous part, and of which the pulse gives notice, but which are not explicable by a knowledge merely of the mechanism of the heart, and of the circulation. It was necessary to look for remoter agencies, by which this mechanism underwent such great and sudden transitions in its movements; as when it is disturbed by fever and jarred by strong emotion, or tbe irritations of other viscera. The pulse, under these circumstances, indicates great cardiac disturbance, but its revelations of more remote disorder were not always read in the proper sense. Something more than the blood, the normal stimu- lant of the heart, was to be studied: it was necessary to discover tbe connecting links between the heart, the central organ of the circulation, and the brain, tbe material organ of the mind, or great ganglionic centre of intellectual and emotional life, and also be- tween the heart and the ganglionic centres and plexuses of nutritive or organic life. The nerves are these connecting links; and now, when we feel a pulse in a case of fever, we ought to be aware that we seek in the number and character of its beats an index, not only to the momentum with which the blood is impelled by the contrac- tile power of the heart, but also the possible mental disturbance, and, still more certainly, the irritation or inflammation of a viscus, or it may be of several viscera or tissues, which, by a continual teazing, as it were, of the heart and the brain, keep up what we call fever. But the blood itself, in the artery beating beneath our fingers, has also its share in modifying the character of tbe pulse, not only by its quantity, but also by the varying proportions of X 11 poisonous e.e„:„: :thed peLb/ittsh;1;nrduotion °f a ~d but more frequently weaken ntX ? * m sometim^ exciting, of the heart ' WeakemnSthe oontnoftle and propelling power It is impossible, therefor f™ *u experience, and of rel a7ce on ! , *"* "^^ advocate <* to deny, whi.e his l^lZZt^ 7,T ^ " ^^ under fever, the necLtv „f J P h'S pat,eBt> who Iabors cedent phenomena I, * f P °g m meDtal re"» ">e ante- ""•m«onrrr^mr"otion of the h-rt- ~*. outritive life, and ,hobaL1 """"^ T"*™ °f animaI ™d * editing these nervous *" and? "J*8,™*™ m the ««« of the blood, and it »t!^ . ^ 'he a"ered P^Perties vesSe, itee,f;by t-h: sgbe • r fr: ;::laif *m°* .«* <««., a practical man he is hn,!„,t re iculated nervous tissue. As if he draws i2Z^Z^l°"?m *" mi°d aI1