'v? 1 . % <5> <\^' >:" v %y^ ^p- < *^A- ZA. \z O CONFERENCES ON THE MORAL PHILOSOPHY OF MEDICINE Virtue, knowledge, health, and activity are the primal sources of felicity of the student and physician Moral rectitude, untiring industry, natural aptitude, and quick perceptions are the highest attributes of the genuine student and physician The advancement of science, justice tempered with mercy and generosity, fidelity to duty, hope of lasting usefulness, and charity toward humanity, are the noblest aspirations of the true physician CONFERENCES ON THE MORAL PHILOSOPHY OF MEDICINE PREPARED BY AN AMERICAN PHYSICIAN " Nil dictum quod non dictum prius" NEW YORK REBMAN COMPANY 1123 Broadway LONDON REBMAN LIMITED 129 Shaftesbury Ave., W.C. Copyright, 1906 By REBMAN COMPANY New York Copyright, 1906 By REBMAN LIMITED London, England Printed in A merica Eo THE MEMORY OF THOMAS PERCIVAL, M.D., F.R.S.LOND., etc., etc. AS A TRIBUTE OF THE HIGHEST APPRECIATION OF HIS IMPERISHABLE CONTRIBUTION TO THE MORAL PHILOSOPHY OF MEDICINE THESE PAGES ARE REVERENTLY INSCRIBED PREFACE This manual, consisting of a series of con- ferences on some of the principles of the Moral Philosophy of Medicine, gathered from authen- tic sources, is intended for the use of medical students and young physicians. Certain ap- pended documents are designed as memoranda to serve in the study of the history of that part of medical morals which especially concerns the American profession and the people. CONTENTS PAGE Introductory Note 1-2 I THE ASPIRANT TO MEDICAL STUDENTSHIP Answers to the aspirant's queries. The terms physic and physician. The nature and extent of the phy- sician's mission. A glimpse at the medicine of early times. The term chirurgery. The slow ad- vance of the healing art during many ages, and its rapid progress in the nineteenth century. The true physician of the present, his labors and re- sponsibilities 3-17 II PHYSICIANS OF THE PAST The aspirant's desire to know something of physicians of the past. A few biographic notes illustrative of devotion to the art and science of medicine. The early cultivation of anatomy by Alexandrian phy- sicians. Arabian physicians. The great physi- cians of Italy, Belgium, Holland, Denmark, Ger- many, France, England, and America >8-34 III TEACHERS, SCHOOLS, AND STUDENTS OF MEDICINE Medical teachers in ancient times. The temple schools. The Crotona school. The Hippocra- tic school. The Alexandrian school. The Saler- IX CONTENTS PAGE nian school. The schools of France monastic from the tenth to the fifteenth century. The Italian, French, and Dutch universities. Desault and his colleagues the beginners of the modem Parisian school of medicine. American teachers and schools. The American medical student. The student of the twentieth century 35-52 IV THE MATRICULATED STUDENT Answers to the matriculate's queries. Note taking; its value as an aid to memory, as a guide to read- ing, as an assurance of accuracy in debate, and as a serviceable adjunct in learning the art of writing with precision and clearness. The attendance of lectures on other than medical subjects. The class society. What the student should read be- sides medical works. Physical exercise, diet, sleep, and social duties of students. Relations of students to their teachers, and to each other .... 53-69 V ♦ THE GRADUATE AS HOSPITAL-INTERNE Relations and obligations of hospital-internes to each other, to members of the Medical Board, and to the lay officers. Reciprocity. Hospital discipline The main forms of procedure to subserve the inter- ests of patients and the efficiency of the medical staff. Criterion of conduct of members of the house-staff. Conduct of the medical officers in the operating room 70-85 VI THE YOUNG PRACTISING PHYSICIAN Requisites to professional success. The early years of medical practice. The acquirement of a clientage. The labors, anxieties, responsibilities, and vexa- X PAGE tions of the physician in full practice. The growth of a physician's library. His equipment in medi- cal implements. His iatrium. His obligations to the profession. When to begin writing for publi- cation. Avoidance of controversy. The review of medical books. The question of specialism. The evil of self-sufficiency. The physician in politics 86-104 VII SENSE CULTURE VISION AND AUDITION The early cultivation of the senses essential to the proper conduct of the study and practice of medi- cine. General remarks on the five senses. The visual sense. Seeing with the mind's eye. Quick- ness of visual perception; its importance to the physician; how to exercise it. The auditive sense. Exercise of the mind's ear for correct interpreta- tion of heart and respiratory sounds, etc. Music as an aid to the cultivation of audition 105-121 VIII TACTION, OLFACTION, AND GUSTATION The tactile sense. Its nature and diffusion. All the other senses modifications of touch. Sensitive apprehension, sensibility, and sensation; their signification. The achievements of man through cultivation of the sense of touch. Some of the modes of culture of direct and of mediate taction. Olfaction culture. The olfactive cells. The spe- cialisation of odors. The game of perfumes. Taste culture. The seat of gustation. The five savors. The concurrence of the tactile and olfac- tive senses essential to perfect gustation 122-141 IX EVOLUTION OF MEDICAL MORALS A summary of the history of the evolution of medical morals. Beginning of the indoctrination of indi- CONTENTS XI PAGE vidual obligations. Reciprocity a word of com- mand. Justice, mercy, generosity, hope, faith and charity the fundamental maxim of all systems of good morals. A glance at the Hippocratic oath, law, iatrium, aphorisms, and prognostics. Collo- cation of moral precepts by Dr. Thomas Percival. The American system of medical morals, its origin 142-158 X THE PHYSICIAN AND HIS PATIENT Relations and obligations of the physician to his pa- tients. Prompt obedience to the calls of the sick. Attention, steadiness, and fidelity. Indulgence to the caprices of the sick. The obligation of secrecy extending beyond the period of professional serv- ices. A physician obtaining information in his professional capacity not bound to reveal it in any court of justice. Of necessary and unnecessary visitations to the sick. Gloomy prognostications not to be made within hearing of patients. Con- duct as regards attendance on incurable cases. The division of responsibility in the management of serious and difficult cases 1 59-176 XI THE PATIENT AND HIS PHYSICIAN Reciprocal obligations of patients and their physicians The patient's selection of a physician. Prompt obedience to the directions of the physician either toward the prevention or cure of disease. Impor- tance of seeking advice at the earliest manifesta- tion of any sickness. Irrelevant and wearisome details in the statement of his case to be avoided by the patient. Strict observance of the rules prescribed during convalescence. No friendly visits from physicians who are not in attendance. The patient to be always in readiness to receive his physician >77*>93 CONTENTS XII CONTENTS XII THE PHYSICIAN, PROFESSION, AND PUBLIC PAGE Obligations of physicians to the profession and to each other. Maintenance of the dignity and honor of the profession. Extension of the bounds of its use- fulness. Contributions of lore to enrich the sci- ence of medicine. Criterion of the true physician. Temperance in all things. The physician's medi-' cal adviser. Vicarious offices. Duties in consul- tations and in cases of interference. Differences between physicians. Pecuniary acknowledgment and compensation. Relations of the profession and the public 194-213 XIII THE LANGUAGE OF MEDICINE Correct, simple, concise, and clear medical language as essential to the conduct of instruction as the cultivation of the senses is to the study and prac- tice of medicine. The young physician beginning to write for publication. Word controversies. Misused words. Wrongly coined words. Vicious locutions. The drilling of students in the use of words of precision. Frequent revisions of essays 214-234 XIV 'young writers and speakers How to master the art of intelligible medical writing. The use and abuse of figures of speech. Word coining. Obsolete words. Misusage of terms. Alliteration. Florid writing out of place in medi- cine. Quotations. Short and long sentences. The proper disposition of members of sentences. The good of frequent revisions. Punctuation. Medical "bulls." Style. Titles of essays and books. Individual titles. Preface. Introduc- tion. Epigraph. A few cautionary remarks for the benefit of young speakers 235-252 XIII CONTENTS XV LENGTH OF LIFE OF PHYSICIANS PAGE To live long and be useful the physician must begin his career by living rightly. Mortality among physicians between the ages of twenty-one and forty. Average length of life of the physician. . The question of retirement from practice and other work. Advanced age per se not a condition necessarily disqualifying a medical man from pro- fessional duties. Senility not to be measured by length of years but by infirmities of body and mind. Longevity among eminent physicians. Examples of physical and mental activity in aged physicians. No good reason for retirement except physical or mental disability 253-272 APPENDIX Note 275 I The Hippocratic Oath and Law . . . 276 II The National System of Medical Morals 280 III Remarks on the National System . . 304 IV The Explanatory Declarations . . . 308 V Remarks on the Explanatory Declara- tions . . . • 310 VI The Abstract of the National System . 312 VII Remarks on the Abstract 328 VIII An Analysis of Dr. Flint's Commentaries . 332 XIV Conferences on the Moral Philosophy of Medicine INTRODUCTORY NOTE In these conferences which consist chiefly of the trans- ference of ancient precepts to modern language and pur- poses, nothing is said relating thereto, that has not been voiced before, but some of the utterances may seem new to beginners; to others they may serve as reminders; and to all they will be salutary. That the systematic teach- ing of medical morals should constitute the early part of the student's education is evinced by the frequently expressed desire of young men to obtain the right kind of information for guidance in their professional relations and obligations. The moral philosophy of medicine, comprising as it does the science of the physician's duty in all his acts and concerns, the thorough knowledge of the laws of medicine and of the relations of the student as well as the graduate with his associates and other members of the community, seems a suitable title for these colloquies which consist of an exposition of some of the general and special principles of conduct of the aspi- 1 MORAL PHILOSOPHY OF MEDICINE rant to medical studentship, of the matriculated student, of the hospital-interne, and of the young practising phy- sician, and include considerations on physicians of the past and present, on medical teachers, schools, and stu- dents, on the early cultivation of the senses as essential to the proper conduct of the study and practice of medi- cine, on the evolution of medical morals, on the special relations of the physician and patient, of the physician and colleagues, and of the profession and public, besides a discourse on the language of medicine, another on young writers and speakers, and a third on the length of life of physicians. 2 I THE ASPIRANT TO MEDICAL STUDENTSHIP Answers to the aspirant's queries-The terms physic and physi cian-The nature and extent of the physician's mission-A glimpse at the medicine of early times-The word chirurgery -The slow advance of the healing art during many ages, and its rapid progress in the nineteenth century-The true phy- sician of the present; his labors and responsibilities. In undertaking the pleasant task of setting forth some of the long-established principles by which students and young physicians are guided in their worldly and pro- fessional intercourse, it has seemed wise to do so chiefly in the form of queries and answers; beginning with the aspirant to medical studentship. When a young bachelor of arts thinks it time to select a profession, if his inclination be toward that of medicine, his first act, in all likelihood, will be to solicit the advice of his family's physician. In case of a favorable decision, the adviser and friend generally becomes his sponsor and, in due time, gives him the necessary credentials of moral, intellectual and physical fitness and special aptitude for the study of medicine. Having determined to be a med- ical student he expresses to his sponsor the desire to ob- tain certain items of information concerning the profes- sion whose ranks he hopes to enter. This inquiring 3 MORAL PHILOSOPHY OF MEDICINE propensity is encouraged because it is one of the good means by which to acquire the more quickly much of the needed knowledge, and by which, at once, are made known to the beginner those precious rules of conduct pointing the right path to be followed throughout his professional career. The character and the ready and comprehensive answers as well as the personality of the sponsor generally make a strong and lasting impression on the inquirer's receptive mind and retentive memory. His questions, which he is enjoined to formulate with care, and the replies he receives, often serve to confirm, to elucidate, or to supplement what he may have read or heard, for the sponsor sometimes follows the plan, adopted by certain teachers, of reversing the order of the quiz; the pupil asking the questions. This is very profitable to the learner, for the answers are generally accompanied by comments and illustrations derived from mature experience. By striving to question rightly, the inquirer soon learns to reply intelligently; so his early queries are answered in good faith howsoever strange they may seem. Among the pertinent questions he is wont to ask are: What was and is physic? What is a physician? Whence these titles? What is the nature and the extent of a physi- cian's mission? To answer these questions intelligibly, the sponsor says, requires a short preliminary statement of the early use of the terms physic and physician; of the beginnings of the art of healing; and of the slow progress of the science of medicine during many centuries and of 4 ASPIRANT TO MEDICAL STUDENTSHIP its steady advancement to the present time; and begins with the term physic as follows: The Greek physike, and the Latin physica were used originally to designate natural science, but insomuch as medicine was soon recognised as a branch of natural sci- ence, the word physic came to be used for its designation and the title physician to be applied to him who prac- tised the healing art. There exists a record to that effect in the decreed 'of the Council of Tours held in the year 1163. But even before that time physical science was understood to comprise such knowledge of the human body as to enable the physician to guard its health and cure its diseases. To designate the physician, the Greeks had used originally the word iatros* healer; and the Latins, from mederi, to heal, had derived medicus, healer; and the Latin races of to-day preserve the parent form, as the Italian and Spanish medico, and the French medecin. The word physician is now used chiefly by English speak- ing people. In England, the vague, indefinite, incorrect term practitioner is applied to any physician, but more particularly to him who practises both medicine and surgery; sometimes qualifying it with the adjective gen- eral. The French term praticien, with medecin prefixed was anglicised practician without the prefix medical; while practicianer was also employed as were physicianer, musicianer, and other kindred forms. The word was * According to Sextus the empiric, iatros comes from ios, arrow or dart.-Histoire de la Chirurgie. Dugardin. p. 3, foot- note. 5 MORAL PHILOSOPHY OF MEDICINE afterward spelled practicioner from which probably arose the final corruption practitioner. It is hoped that the American physician will no longer suffer himself to be called "practitioner" or even practician, for he is a practiser of physic, and for brevity a physician. In very early times there was no system of physic; each sufferer, like the beasts of the fields, using such means of cure as instinct dictated or, afterward, as were suggested by another sufferer who had derived-benefit from certain remedial agents, an account of which he was required to deposit in some public place or temple. This was the early custom in Assyria, Egypt, and Greece. As votive tablets and other like documents accumulated in the temples they were suitably arranged, revised, and tran- scribed by the priests to whom only they became acces- sible and who consulted the work, which was known as the "sacred book," to find the remedies applicable to the cases.of disease under their observation. Such, in Greece, was the practice until the great reformer Hippocrates came to the front and finally etablished a sound system of medicine; bequeathing to the world such an imper- ishable record of his greatness in the science and litera- ture of the healing art. Notwithstanding the Hippo- cratic school, the priests, who had a powerful hold on public credulity, would not relinquish the practice of healing diseases in their crude way and, for a long time, continued to be the medical advisers of the majority of the Greek people. In Egypt, none but the priests were permitted to minister to the sick and, says Herodotus, 6 ASPIRANT TO MEDICAL STUDENTSHIP there was one specially devoted to the treatment of each kind of disease. There then was the birth of specialism. Among the early Israelites the prophets, priests, and Levites were the only physicians. This ancient custom of combining the offices of physician and priest was adopted by the Christian clergy and prevailed, with but few exceptions, until the middle of the eighteenth century. Although the school of medicine of Salernum, celebrated by the many learned members of the clergy who there were taught and then taught the medicine of the Arabs as well as that of the Hippocratic school, had existed since the eighth century, as did the school of law of Bologna and of theology of Paris,* and although the great colleges of Oxford and Cambridge in England, were founded late in the ninth century, it was really during the thirteenth century that the greatest impulse was given, not only to the congregation of scholars under the title of University but to poetry, to song, to church music, to architecture, to art, to literature, to physical, mental, and sensual culture, and to medicine. It was through those flourish- ing scholars then that occurred the great revival of gen- eral learning which had so sadly fallen after Tarsus, Athens, Rome, and Alexandria had ceased to be intel- lectual centers. The vast debt due to those devoted schoolmen by modern thinkers remains uncancelled not- withstanding the tacit acknowledgment that learning * The University of Paris was originally started toward the end of the eighth century through the influence of Alcuinus who became one of its first professors. 7 MORAL PHILOSOPHY OF MEDICINE is generally developed and extended by the scrupulous study of the contributions of laborers of the past. As the immense progress of science in the nineteenth century depended largely on the preparatory labors of the eigh- teenth century, so, doubtless, will the accomplishments of the nineteenth greatly stimulate further advancement in the twentieth century, and this last on the acts of suc- ceeding ages in medicine and in all other branches of science and art. In the twelfth century priests were forbidden to practice surgery, that is to say, to use the knife and shed human blood, or to use the actual cautery, and even to study medicine. But during the crusades, and when leprosy was imported to western Europe, the lepers' hospitals were attended entirely by monks. There came two more prohibitions in the twelfth century, and a fourth in the latter part of the thirteenth century, under the pontifi- cate of Boniface VIII. The law of celibacy imposed, in France, upon physicians, was abrogated, in 1452, through the influence of Cardinal d'Etouteville. This should have placed medicine entirely in the hands of the laity. It did not, however, for the clergy continued to practice medi- cine. The final decree, prohibiting priests from practis- ing medicine or surgery, was promulgated, in the middle of the eighteenth century, during the pontificate of Bene- dict XIV. The term medicine or rather its equivalent, was applied to the art of healing wounds long before internal diseases were understood. Machaon and Podalyrius were highly 8 ASPIRANT TO MEDICAL STUDENTSHIP prized at the siege of Troy both for their feats of arms and for their skill in the treatment of wounds; they were iatroi, healers, as well as warriors. The word chir- urgery xupovpyca, relating to manual operations upon the human body was not in use until the time of Herophilus 307 B.C. (Celsus). A few centuries ago the word surgeon was employed to designate the "barber-surgeon" and so distinguish him from the educated healer who was styled "Master in Chirurgery." In France, as early as the be- ginning of the fourteenth century, no barber-surgeon was permitted to exercise his calling which was to shave men's faces, cup, bleed, administer glysters, and perform other minor and menial operations, until he had been examined by a Board of Masters in Chirurgery or Maitres-Myres.* * As the student may find, in some old books, the word mire or myre, it is well that he should understand the meaning anciently given thereto. In olden times the masters in chirurgery were designated mires or myres, as some writers have supposed, from Robert Le Myre, an eminent surgeon of Paris, sworn in the guild by Jean Pitard who had established the College of Chirurg- ery during the thirteenth century. This Le Myre was in such high repute among the people on account of his personal quali- ties and surgical skill that, at length myre came to be the popu- lar designation of every accomplished surgeon. Finally the official title of myre was given by the Faculty to all sworn sur- geons, as M attres-Myres. Surgery had then become almost hereditary in the family of Le Myre, as medicine was in that of the Asclepiades, and as lithotomy was in the Colot family. Other writers derived Myre from myrrbe signifying perfume, but the differing orthography of these words dismisses the supposition that myre was derived from myrrh. There are also those who made myre come from the Arabic emyr, or from the old French myr taken from the Latin myrus, because the marvelous of the healing art caused the medecins-chirurgiens to be regarded as men of high merit, of high status or occupation-hommes de 9 MORAL PHILOSOPHY OF MEDICINE The generic term physician is, however, quite sufficient to designate both the surgeon and the physician as they are now styled. Medicine began to advance rapidly from the middle of the eighteenth century, but its march has been marvelous in the nineteenth century during which so many discov- eries were made in general, special and morbid anatomy, in the development of the embryo, in the specialisation and significance of bacteria, in bio-chemics, in therapy and in other collateral branches; and there are yet to be made much greater advances for ages to come. Its ever progressive tendency and its broad eclecticism, render medicine one of the most interesting and fascinating of studies; laying under contribution, as it does so exten- sively, nearly every other branch of science, and keeping a steady vigorous step with all in their grand onward march; so that in the cultivation of medical science there will always be abundant opportunities for discover- ies and for distinction. The twentieth century students who shall have delved into medical history will fully grand etat. The Salernum physicians were called mires. In the " Roman de la Rose," mire is employed to designate those who ministered to internal as well as those who cured external dis- eases. Mire, mege and miege appear to have had the same signification and to have been derived, by some writers, from the Latin mederi, to heal. It is needless to add anything more to this abstract from the interesting though very long logophilic dissertation of Girodat, except to say-he acknowledges that the word mire signified medecin-chirurgien as early as the tenth century or at least three hundred years before the time of Robert Le Myre. But according to Borel the old Gallic mire comes from mwron unguent.-Loc. cit. Dujardin, p. 3., footnote. 10 ASPIRANT TO MEDICAL STUDENTSHIP realise how great were the difficulties and disadvantages under which their early predecessors labored in creating the art and science of medicine whose development was necessarily so slow. The first discoverer probably observed only the effect, the symptoms, while another learned the cause, and a third found the generic substance and its properties. Then arose investigators who discovered species and varieties of diseases; and long thereafter came those thinkers who were able to interpret the phe- nomena and apply remedial means appropriate to each species. It was not until the close of the eighteenth cen- tury that really began the systematic study of diseases on a truly rational basis, and this was the forerunner of the great progress made in the nineteenth century. The pioneers were Sauvages, Linnaeus, Cullen, and other eminent physicians. Nothing is more helpful to the modern student of the natural history of human diseases than the acquirement of a mastery in their nomenclature and classification. The requisite training gives him a precision in diagnosis, a degree of wisdom in prognosis, and a skill in therapy, which otherwise he could never attain. The true physician of the present time is a biosophist devoted chiefly to the healing of human ills, to accom- plish which he has made himself thoroughly acquainted with the structure and functions of the normal body of man and with deviations therefrom; with the nature and phenomena of morbid processes; with the best means of diagnosis; and with the properties, effects, and medicinal 11 MORAL PHILOSOPHY OF MEDICINE value of the remedial agents employed; and is a wise prognostician; besides which he formulates rules for the prevention of disease, and thus ministers to public health. He is learned in the natural sciences and skilled in the art of healing. Hence his title physician. But his mis- sion extends far beyond this. He is a friend of the family of whose secrets he is often the trusted custodian, judged by his high character to keep them inviolate as enjoined by the Father of medicine. He is also, on many occa- sions the happy and blessed peace-maker in family feuds of long duration through some slight error on both sides, or credence in evil reports. When asked to sit in judg- ment, it is generally with the distinct understanding that both plaintiffs and defendants shall abide by his decision. This common occurrence has resulted in the happy re- union of families that had seemed to be hopelessly divided and that had lived in enmity for many years. He is sometimes consulted about contemplated marriages and his advice is generally followed. Would that this were much more frequent, for the good of the bride, of the groom, and of the progeny! The prudent young mother and the physician hold a conference, toward the close of each season, concerning the proper time to make a change in the character of the family's raiments, and is invari- ably guided by the advice she receives. The decision respecting the kind and amount of physical exercise adapted to the condition of each member of the family is also referred to the physician. Both parents, often solicitous about the literature to be cultivated by the 12 ASPIRANT TO MEDICAL STUDENTSHIP adolescents of the family, and aware of the influence reading matter exerts upon intellectual development and morals during that impressionable period of life, naturally appeal to their best friend the physician for suggestions. The site of a country residence for a young family is fre- quently determined by the physician with a view to salubrity.* The farmer is wont to consult his neighbor- ing physician, not only about his own and his family's health, but concerning the hygiene of his cattle and pigs, and the readiest mode of destroying the parasites that infest his trees or those that injure his crops. On frequent occasions the physician is the family's arbiter bibendi and is well qualified for the office. When asked what and how much to drink, the quality and quantity of beverage he prescribes are generally accepted. * Influence of the Physician on the Nation.-The physician can in no possible way serve the nation better than by teaching the mothers of the nation how to rear the children of the nation. It is the physician who comes in deliberate contact with the daily family life and who speaks and they believe. The physi- cian is the physical guardian of the rising generation, and de- termines in a great measure the character of the spiritual, commercial and political life of the nation; in fact, he aids the peo- ple of the nation to receive what they have a right to demand. As a result of his having lived and lived nobly, there will be happier homes, fewer disappointed lives and less crime; in such a capacity, and from a standpoint of national work, the physi- cian is the most important member of the community in which he resides. A more valuable man to the state or nation than a man in any other calling, who prepares the soil, and without sound bodies and normal minds, sacred and religious teachings are of little avail. Where the nation shall stand twenty-five or fifty years hence, and what position it shall occupy among the nations of the earth, depend more on the physicians of to-day than on any other calling whatever.-Charles Gilmore Kerley. 13 MORAL PHILOSOPHY OF MEDICINE He is ever ready with the old saw-"good wine maketh glad the heart of man,'' but enjoins moderation and condemns the amount of imbibition that causeth some- thing more than precordial gladness. He is generally an excellent judge of wine through his knowledge of its chemistry, and the high cultivation of his gustative and olfactive senses. Some of the best works on beverages in general and wines in particular have been written by physicians, as those of Sir Edward Barry, M.D.; Doctor Henderson, Doctor Thudicum, and several other bright lights of the profession, besides the charming poem, Bacchus in Tuscany, by Doctor Redi. In the country, when the physician is called upon to examine drinking water from wells or springs, his prompt statement of the results of such examination has often averted serious consequences of the use of polluted water. The potabil- ity of some particular milk, and even of certain tea or coffee infusions is not unfrequently left to his decision which is generally speedy, as it should be, regarding their safe or unsafe use. The physician is also the family's arbiter edendi; pre- scribing the quality and quantity of food and its best mode of preparation to render it wholesome, tasty, and appetising; particularising the kinds best suited to the infant, the child, the adolescent, the adult, and the aged; and directing the cookery adapted to the sick. He regards the kitchen as a laboratory of alimentary chem- istry conducted by a fair chemist from above stairs. For many ages, physicians have been noted for their 14 ASPIRANT TO MEDICAL STUDENTSHIP love of good cheer, but the greatest deipnophilists among them have invariably and constantly preached and prac- tised moderation; often quoting Brillat-Savarin's aphorism to the effect that "those who feed to surfeit and tipple to saturation know not how to eat or drink." One of the most eminent of the deipnophilists of the beginning of the nineteenth century was the learned Doctor Castaldy, Regent of the Montpellier school of medicine and Presi- dent of the celebrated Jury Degustateur. He was en- dowed with an excellent constitution, a dainty appetite, a good digestion, and the most delicate gustative sense. He knew well all the good wines and enjoyed them, together with the best approved edibles, always with the moderation of the true gourmet. The preceding is but a condensed statement of a small part of the grave and extended responsibility of the loyal physician in his mission of alleviating suffering and of curing or preventing disease. His private practice is ordinarily less fatiguing than his purely scientific labors and the gratuitous work he performs in public institu- tions. But the aspirant's queries must be answered. His thirst for information is unquenchable, he wants it all at once and cries loudly for more and more; little dreaming of how much more there is to be said without the least danger of exhausting the subject. He now asks: "If the physician performs gratuitously so many varied private and public acts of beneficence, what does he expect, and how is he to live, unless he be a man of inde- pendent pecuniary means or is subsidised by the State?" 15 MORAL PHILOSOPHY OF MEDICINE The physician is not a plutocrat nor is he subsidised by the State, and the community makes no kind of recogni- tion for his extra services. Whilst all the lay employees of public institutions are liberally salaried, the attending physicians receive no pay for their indispensable services. It is for the rising medical men of this twentieth century to demand the recognition to which they shall be justly entitled for the onerous labors assigned to them in public hospitals. Even if he were paid for his public services, the greater part of the true physician's work, which com- prises much laborious scientific investigation, would still continue to be comparatively unremunerative pecuniarily. For this labor of love, he expects no recompense other than the approval of his professional brethren, the satis- faction of doing good, and the happiness of aiding in the advancement of science to the end of relieving the suf- ferings of mankind. For the lesser part of his endeavors, which consists in the private practice of medicine, he does receive some, though generally inadequate pecuniary acknowledgment from ordinary clients whose conscience sometimes whispers to them that the faithful laborer is worthy of his hire. However, there are many clients who show genuinely affectionate gratitude to their physicians. Those persons who may wish to enter the ranks of the profession with expectations of great pecuniary gains need not waste a single minute to the further consideration of the question, but go elsewhere for the worship of mammon, lest they make the noble profession of medicine the vilest of trades. 16 ASPIRANT TO MEDICAL STUDENTSHIP The true physician has always been liberal in all things, never self-seeking from the time of Hippocrates to the present. No bribe offered to that glorious founder of the science of medicine could ever induce him to deviate in the slightest degree from his high principles. Among his noble deeds was the rejection of the golden treasure and other precious objects sent by Artaxerxes as an inducement to desertion of his loved country. The in- tegrity, honesty, and devotion of the true physician of all times has generally secured to him the respect, endear- ment, and unbounded confidence of his patients, par- ticularly at moments of great peril. The most remark- able instance of this kind was when Alexander the Great, laboring under a serious illness, asked Critodemus, his physician, to prepare a draught such as would be likely soon to restore him to health. In the absence of the physician, the King was warned by letter that his cher- ished medical adviser was but a false friend who had designs on his life and who would take the opportunity to give him a poisoned drink. When the physician re- turned with the medicine, the royal patient bade him read the letter and, after watching his expression of countenance during this perusal and seeing in it the depiction of indignation and innocence, swallowed the potion and was cured. The foregoing answers to the aspirant's queries being general and likely to awaken a desire for further informa- tion particularly about physicians of the past, an attempt will be made, in the next conference, to gratify this desire. 17 II PHYSICIANS OF THE PAST The aspirant's desire to know something of physicians of the past-A few biographic notes illustrative of devotion to the science and art of medicine-The early cultivation of anatomy by Alexandrian physicians-Arabian physicians-The great physicians of Italy, Belgium, Holland, Denmark, Germany, France, England, and America. Before making special inquiries about the conditions to matriculation, the aspirant is desirous to know some- thing of other physicians besides the few to whose char- acteristics reference was made during the first conference, particularly of some of those who may have illustrated the profession by great devotion to the science and art of medicine and its allied branches; asking if there be among them many examples of unselfish devotion to the sick and suffering by direct or indirect means? This manifestation of a liking for biography being regarded as a good omen by the sponsor, he endeavors to give the pupil bits of information, for future guidance in his study, of the acts of early and modern laborers in the art and science; saying that, in the several civilised lands of this earth, there have been almost countless examples of the greatest devotion to the sick by direct means and also by indirect means chiefly through re- 18 PHYSICIANS OF THE PAST searches in the science of medicine and its collateral branches. Of Greece, the birthplace of rational medicine, only casual mention will be made, and it is needless to speak now of those physicians who flourished between Hippocrates and Paul of /Egina, except of two renowned anatomists of Alexandria. Hippocrates' knowledge of anatomy seems to have been derived from dissection of lower animals, as the body of man was not used for that purpose until a century or more after his time by Herophilus and by Erasistratus both of whom were unjustly accused of human vivisection. Fortunately the unfounded accusa- tion was not made until these two illustrious physicians and other pioneers had made many important discov- eries in anatomy, and it was five hundred years there- after that Tertullian denounced so vehemently those two learned physicians and truly good men who had done so much for useful medical knowledge and for the scien- tific glory of Alexandria. For a long time the phy- sicians of Rome were Greeks, and many of them slaves. Augustus began to place the physicians on a better foot- ing, but it was during the reign of Nero that the first free man obtained the title of archiater. The Arabian school of medicine, which adopted the Galenic doctrines and became famous, arose during the eighth century of the Christian era. Its development was fostered by the Caliphs of the House of Abbas, particu- larly Haroun al Rashid. Among the physicians em- ployed by these Princes were the two Bachtishuas, father 19 MORAL PHILOSOPHY OF MEDICINE and son, Christian Hindoos. The broad-minded Caliphs, devoted to the cause of science, were led to encourage immigration of learned men irrespective of nationality or religion, and so opened the doors of Bagdad to Greek, Persian, Jewish, and Christian physicians, who became the early teachers and practisers of medicine in the do- minion. Rhazes, Avicenna, Avenzoar, Averrhoes, Albu- casis, and other notables were their successors in Bagdad, in Spain and elsewhere. Italy, that may well boast of her great Celsus who con- tributed to the literary world such an admirable account of practical medicine down to his time, gave birth to very many faithful laborers whose names and deeds so grace- fully ornament medical biography. The establishment, twelve hundred years ago, of the renowned Monte Casino school which flourished so many centuries, and out of which came so many illustrious medical men, was the model for the Paris, Montpellier and other schools of medicine. For a long time the medical schools of Italy were wont to send eminent physicians to divers parts of Europe; occasionally as political refugees. Witness the case of Lanfranco (Lanfranc) the Milanese who went to Paris in 1295 and there soon became "Professor in Surgery." Among the more modern Italian physicians of eminence should be specially mentioned Benivieni and Benedetti the two learned physicians of the fifteenth cen- tury, Prosper Alpino, Professor at the Padua University in the sixteenth century and author of Medicina Egypti- orum; Fracastor, as great in poetical as in medical art; 20 PHYSICIANS OF THE PAST Gaspard Tagliacozzi, the inventor of rhinoplasty; Giovanni di Romani and Mariano Santo, the early lithotomists of that country; Cesalpino, anatomist and botanist; Fabrizzio d'Acquapendente so pre-eminent as anatomist and sur- geon; Eustachius, Fallopius, Varolius, Arantius, Baglivi, Lancisi, Malpighi, Bellini, Aselli, Pacchioni, Santorini, Valsalva and Rolando, a glorious group of great discov- erers in anatomy, whose names appear so frequently in students' text-books. Italy has since produced very many other men of vast talent who, by their labors have largely contributed to the advancement and enrichment of the science of medicine. Spain and Portugal, early and late, have sent forth to the world their share of eminent medical men from the time of the Moors to the present. Belgium may well be proud of her son Vesalius, although he left his native soil to take up residence abroad where he was able, after long and laborious investigation, to prepare his great anatomical work so well, so admirably illustrated. Holland gave to the medical world the illustrious Boer- haave of whom it is related that he received a letter from a Chinese mandarin with no other address than ''Mr. Boerhaave Medecin en Europe." Among the eminent physicians of Holland may be specially mentioned Van Swieten one of the disciples of Boerhaave; the able sur- geons Solingen and Stalpart Vander Wiel; and the great teacher of anatomy Ruysch who labored until he had reached the age of ninety-one when, having sustained a 21 MORAL PHILOSOPHY OF MEDICINE fracture of the thigh bone, he caused himself to be carried into the amphitheatre where he took leave of his pupils, but survived the injury and lived three years thereafter. Three other Dutch anatomists of renown should be named: Paaw, Bidloo, and Nuck. Denmark has produced, among other celebrities, the three Bartholins-father, son and grandson-all very remarkable men in medicine; Steno the anatomist whose name is given to the parotidean duct; Callisen another distinguished anatomist and surgeon; and the great Winslow who afterward went to Paris as a teacher of anatomy. Sweden would be well satisfied to have given birth to the great Linnaeus even if she had not produced many other men of much renown. Norway, Finland, and Russia have furnished their quota of eminent laborers in the advancement of the science and art of medicine. Germany has contributed very largely to medical sci- ence and art during the seventeenth, eighteenth and nineteenth centuries. At the head of the list is the honored name of the illustrious surgeon Fabricius Hil- danus, who, however, won his celebrity in Switzerland. Then follow Hartmann the historian and the marvelous Albinus; and soon Meibom, Brunner, Peyer, Heister, Vater, Richter, Hebenstreit, Liberkeuhn, Meckel, Gruner, and Hesselbach; all men of great eminence, either as surgeons or as discoverers in anatomy. Besides those just mentioned there soon arose to pre- 22 PHYSICIANS * OF THE PAST eminence many other patient and gifted laborers among whom may be particularly named Kurt Sprengel, cele- brated as professor at Halle, and as medical historian; Dieffenbach, the great surgeon; Johann Muller, of cell theory celebrity; and so down to Virchow who, after making prodigious advances in patho-anatomy, devoted his last years to the study of primitive human forms. Many of his survivors are eminent in their several depart- ments of the science and art of medicine. Austria can boast of her great pioneer patho-anatomist Rokitanski, and of many other workers of the highest rank in medicine and surgery. Swit^erland, also aside from her great Haller, and Plater, has an excellent record in her production of true physi- cians and learned men, not the least of whom was the erudite Daniel LeClerc, the historian of ancient medicine. France is justly proud of her sons, the results of whose labors have been such a blessing to the human races ever since the foundation of the great medical schools of Paris and Montpellier. Few of the early works of medi- cal writers of France, during the middle ages, have been preserved; among them those of Gilles de Corbeil (/Egidius Corbeliensis) written in Latin verse during the second half of the twelfth century at Corbeil near Paris. Gilles had studied medicine at the Salernum school and returned to France where he became first physician to King Philip Augustus. He was Dean of the Faculty of Paris and there taught medicine; dying very early in the thirteenth century. Toward the latter part of the same century was 23 MORAL PHILOSOPHY OF MEDICINE instituted the College of Chirurgery through the efforts of the devoted Jean Pitard who associated with him Lan- franc and others; the result being the uplifting of medical education. Nearly three centuries thereafter, appeared the surgeon of Francis I., Guillaume Vavasseur who, in 1544, obtained for the surgery of Paris the privileges of the University. In the same (sixteenth) century flour- ished the great teacher of anatomy Jaques Dubois, known as Jacobus Sylvius, who had Vesalius as pupil and Fernel as colleague, and whose name is so well known to students of anatomy of all countries. Then followed Pierre Franco who was skilled in the operation for cata- ract and in the treatment of herniae, and who was the first to extract a stone from the bladder by the supra- pubic route. He had as contemporary the illustrious Ambroise Par£ who so greatly improved on the current surgery from Guy de Chauliac to his time, and who sub- stituted, for boiling pitch and the use of the actual cautery as haemostatics, the application of the ligature to bleed- ing arteries, probably without being aware, at the time, that Celsus was believed to have recommended the appli- cation of two ligatures to a wounded blood-vessel, one above and the other below the bleeding point, and the immediate excision of the intervening part of the vessel. Mention must now be made of the scholarly Ren£ Chartier who spent so much time, besides his whole fortune to- gether with that of his family, in translating into Latin, with copious notes, and editing and publishing the works of Hippocrates and of Galen, printed in nine folio volumes. 24 PHYSICIANS OF THE PAST In the seventeenth, eighteenth and nineteenth centuries France possessed such a wealth of eminent medical men that it would not now be possible to do more than men- tion the names and some of the deeds of but a few of them. Riolan, who died in 1657 at the age of eighty, was one of the greatest anatomists of his time. He was physician to Henry IV., professor of anatomy, and the loyal defender of the privileges of the Faculty. His successor was Guy Patin the learned professor of surgery at the Royal Col- lege; elected Censor of the Faculty in 1642, and Dean in 1650. As shown in his published letters, Patin was an ardent emule of Botallus in the advocacy of phlebotomy which was still the rage in the time of Le Sage who so amusingly satirised its practice in his depiction of Doctor Sangrado. Bienaise, who died in 1681, was noted for his bistouri-cache which suggested Frere Come's litbotome- cacbe, although Franco had used a lithotome constructed on the same principle. Bienaise was a surgeon of much distinction, selected to follow Louis XIV in his wars against Flanders. Then came the celebrated anatomists Vieussens and Littre, and Dionis, professor of anatomy and operative surgery in the Royal Garden, and another eminent anatomist Lieutand. 'The brightest stars in the surgical firmament of the eighteenth century were Jean Louis Petit; Lapeyronie the founder of the Royal Academy of Surgery; Morand its perpetual secretary, Louis his successor; and Desault and Chopart. Honorable mention must be made of Dujardin and 25 MORAL PHILOSOPHY OF MEDICINE Peyrilhe, the authors of the history of surgery from its origin to their time. Dujardin wrote the first quarto volume, published in 1774, and died, aged thirty-nine, a year after the completion of the work, exhausted by his continuous labors. Peyrilhe wrote the second and third tomes, but only the second was then published. This work of the greatest erudition is of immense utility to students of the early history of the art. Another bright light of French surgery was Portal who attained the advanced age of ninety, dying in 1832. He was the author of a history of anatomy and surgery, and the founder, in 1820, and perpetual president of the Royal Academy of Medicine, and had become the first physician of Louis XVI11., and member of the general council of the hospitals. Corvisart, one of the greatest physicians of the latter part of the eighteenth and beginning of the nineteenth century, was the successor of Desbois at the Charity Hospital as early as 1788, and, in 1799 was made pro- fessor of medicine at the College of France. Later he was the first physician of the Emperor Napoleon and enjoyed many other honors. Bayle, Laennec, and Du- puytren were his disciples. His writings were few but good. Other pupils of the grand school of Paris came forth to do it honor, and to bless their loved teacher of anatomy Beclard the worthy contemporary of Corvisart. In the early part of the nineteenth century, Bayle, La- ennec, and Dupuytren were in their glory, and were soon followed by Civiale whose introduction of lithotrity was 26 PHYSICIANS OF THE PAST hailed as honorable to surgery, glorious to France, and consoling to humanity; Andral, the great physician; Malgaigne, the author of an exhaustive treatise on bone fractures; Lallemand, Delpech, Bouisson, all great in surgery; Rayer, who enlightened the profession on cer- tain renal affections; Cruveilhier the accomplished writer on special and patho-anatomy; Sappey, another pro- found anatomist; the erudite surgeon Velpeau; the learned Broca, author of a comprehensive treatise on tumors; the great and good Bretonneau's beloved disciple Trousseau, the admirable clinician of vast experience, who cared so devotedly, during fifteen months, for his master's comrade the good, charitable, self-sacrificing, faithful friend, patriotic songster and illustrious poet Beranger in his last illness; Mercier, the father of prostatic surgery; the skilful surgeons Vidal, Nelaton, Maisonneuve, Gosselin, Richet, and Verneuil; Robin, the profound scholar and able teacher of minute anatomy; and many others of the highest merit. Great Britain, too, has reason to be proud of her medi- cal celebrities in England, Wales, Scotland, Ireland, and the provinces in America, Asia, and Australasia. According to Doctor Freind, the historian, the first Eng- lish physician whose writings have been preserved was Gilbert who lived in the latter part of the thirteenth cen- tury. Gilbert's work, cited by Dr. Freind, has for title: Compendium medicince tarn morborum universalium quam p articular turn. The first, says Freind, to be court phy- sician was John of Gladdsden who flourished in the be- 27 MORAL PHILOSOPHY OF MEDICINE ginning of the fourteenth century; and the first surgeon was John Ardern who lived at Newark from 1349 to 1370 when he went to London. Linacre, the great scholar and court physician of the fifteenth century, devoted his gains to good deeds and finally to the foundation of the College of Physicians. His friend successor and emule, also an accomplished Hellenic scholar and learned physician, was that Doctor Kaye or Caius whose character was so misunderstood, misinterpreted, and unjustly satirised by Shakespeare in his play "The Merry Wives of Windsor," and who was another example of self-abnegation and devotion to sci- ence and good works. Another remarkable man was William Harvey to whom is owing the discovery of the circulation of the blood after long study and experimentation, with no expecta- tion of reward. But the name of Harvey is embalmed in the memory of men as one of the greatest benefactors of science and of humanity. The next British medical luminary was the sound thinker Thomas Sydenham justly styled the modern Hippocrates. The following, quoted from a biographical sketch of this new reformer of medi- cine, gives a fair idea of the esteem in which he was held: "This great man effected a real revolution in physic, and no one ever had a more just claim to the title of a restorer of true medical science. But his was the tri- umph, not so much of transcendent genius, as of good sense over vague hypothesis; to him the praise belongs of having been an accurate observer who, endowed with 28 PHYSICIANS OF THE PAST great sagacity, conducted his researches with skill, and was guided by a sure method in all his investigations. In a word, no physician ever exerted so beneficial an influence over that branch of the art to which all others are subservient, viz.: its practical application." Then came Mead, the author of Medica Sacra, and Freind the historian of "Physic from Galen to the Six- teenth Century." They were followed by Richard Wise- man, surnamed the Par£ of England; Highmore whose name is known to the students of anatomy from its hav- ing been long connected with the antrum of the upper jaw; and by the three eminent anatomists Glisson, Whar- ton and Willis. The names of Douglas, Cheselden, the Monros father and son, Macbride, Dease, Blizard should not be omitted in this enumeration. Among other great names are: Pringle, who began medical practice while a professor of moral philosophy; the learned Heberden; Percival Pott, the wise surgeon; Cullen, the eminent nosographer; Wil- liam and John Hunter of immortal fame; Richard Warren, "who combined all the qualities which form not only the popular, but the great physician." "The expression of his countenance," says his biographer, "was at once amiable and acute, his comprehension was clear and quick, and unfolded itself to the listener in a prompt, accurate strain, and in language most fortunately chosen The cheerfulness of his own nature, and the power which he possessed of infusing it into others, enabled him to exer- cise over his patients an authority very beneficial to 29 MORAL PHILOSOPHY OF MEDICINE themselves .... such cheerfulness of manner . . . . is one of the surest modes of acquiring the confidence of a patient, and in some cases operates as a restorative of no mean efficacy"; Matthew Baillie, who devoted three years to the study of languages, mathe- matics, and general philosophy, as a preparation for the study of medicine with his uncle William Hunter, "was remarkable for the consideration which he paid to the feelings of his professional brethren, more particularly to the younger branches; punctuality was also one of his characteristics In consultation he was candid and liberal in the highest degree; and so industriously gave credit to the previous treatment of the patient (if he could approve it), that the physician who called him in never failed to find himself in the same posses- sion of the good opinion of the family as he was before the circumstances of the case had made a consultation necessary. His manner of explaining the disease, as well as the remedies recommended, was peculiar to himself, and singularly happy. It was a short compressed lec- ture in which the objects in view, and the means by which they were to be attained, were developed with great clearness of conception, and in such simple un- adorned language as was intelligible to his patient, and satisfactory to his colleague." Baillie had among his contemporaneous laborers in science the justly celebrated discoverer of vaccination Edward Jenner of whom a biographer says: "Among all the names which ought to be consecrated 30 PHYSICIANS OF THE PAST by the gratitude of mankind, that of Jenner stands pre- eminent: it would be difficult, we are inclined to say impossible, to select from the catalogue of benefactors to human nature, an individual who has contributed so largely to the preservation of life, and to the alleviation of sufferings. In whatever corner of the world the bless- ing of printed knowledge has penetrated, there also will the name of Jenner be familiar; but the fruits of his dis- covery have ripened in barbarous soils, where books have never been opened, and where the savage does not pause to inquire from what source he has derived relief. No improvement in the physical sciences can bear a parallel with that which ministers, in every part of the globe, to the prevention of deformity, and, in a great proportion, to the exemption from actual destruction." Of the delvers in medical science who came to the front in Jenner's time, the most remarkable were the three Bells-Benjamin, the sound logician and clear writer and teacher; John, the original, bold and brilliant military surgeon, as skilled with the knife as with the pencil in sketching injured or diseased parts of the body; and Sir Charles, made great by his discoveries in the nervous system, but as great in art and letters as accomplished in anatomy and surgery. His illustrations of surgical operations are as admirable models of accuracy as of artistic skill. His grand work on ''The Anatomy of Expression," although intended for artists, is well worthy of the close attention of the student who will find its matter instructive, its diction pure and copious, its style 31 MORAL PHILOSOPHY OF MEDICINE lucid and elegant and its illustrations splendid produc- tions of the highest artistic genius. Other contemporaries of great eminence were: Sir Astley Cooper; William Hey, Ashton Key; and Sir Benjamin Brodie; and later James Syme; Sir James Simpson; Sir Spencer Wells; Sir William Fergusson; Lord Lister; and a host of learned and skilful successors. The early steps in the prodigiously rapid march of medical science in the nineteenth century were taken by Bichat who created general anatomy, and by Laennec who gave the first great impulse to the study of patho- anatomy. Then came in quick succession great numbers of laborers in cellular anatomy, normal and morbid, in the different countries of Europe and of America. The foregoing notes on foreign physicians were selected because they typify well the character of the true physi- cian whatever may be his nationality, and because those named are so worthy of emulation. However, it is well that the young American should know that his country has contributed a fair proportion of great and good men who have given much help in the advancement of medical science and art. The names of these honored physicians should be deeply graven in the mind of the student and of the young physician, and their great deeds of benefi- cence should serve as vivid examples for emulation to all faithful laborers in the loved science and art. A few only of these bright luminaries of American medicine will be mentioned, they are: William Shippen, John Morgan, and Adam Kuhn, the pioneer teachers of medicine in 32 PHYSICIANS OF THE PAST America; the illustrious Benjamin Rush; Physic and Dorsey, eminent teachers, and authors of works on sur- gery; Chapman, so well known to all students; John C. Warren, Mussey, Nathan Smith, Randolph, Gibson, Dud- ley, Nathan R. Smith, all great men who have so much advanced American surgery; David Hosack, the accom- plished nosographer; Hewson, Morton, Horner, and Par- sons, eminent anatomists; Valentine Mott, the illustrious surgeon who first tied the innominate artery; John W. Francis, the great physician and orator; McDowell, the first ovariotomist; Crosby, Bigelow, Gross, Pancoast, Leidy and D. Hayes Agnew, distinguished teachers of anatomy and surgery; the eloquent Dickson, Alonzo Clark, the great teacher of patho-anatomy and practical medicine; the learned and. versatile Meredith Clymer; Marion-Sims, the noble father of gynaecosophy; Carroll, the eminent sanitarian and accomplished scholar; Da Costa, the brilliant teacher of medicine; Austin Flint, the wise physician, consummate clinician and polished writer; John T. Metcalfe whose rare abilities, tact and cheerful mien won for him a large and lucrative practice; and another indefatigable worker in the broad field of science, full of precious lore and of public spirit, still at hard labor, whose first essay, written in his youth, distin- guished him among writers and statisticians, whose great work on operative surgery made him eminent among teachers, and whose special researches have rendered him illustrious among sanitarians. Others, of the greatest worth, who have done so much toward the "dispersion of 33 MORAL PHILOSOPHY OF MEDICINE the obscuring mists of error by early lighting the brilliant torch of truth," and have thus left the noblest records in every civilised country of the eastern hemisphere and on the American continent, are too many to be added to these lists. Although from the foregoing, he has learned something of those physicians who have shown great devotion to their profession the neophyte is still anxious for further light, particularly respecting teachers, schools and stu- dents. The needed information will be embodied in the next conference. 34 Ill TEACHERS, SCHOOLS, AND STUDENTS OF MEDICINE Medical teachers in ancient times-The temple schools-The Crotona, Alexandria, and Salernum schools-The French schools monastic from the tenth to the fifteenth century- The Italian, French, Dutch, Austrian, and German Universi- ties-Desault and his colleagues the beginners of the mod- ern Parisian school of medicine-American teachers and schools-The American medical student-The students in the twentieth century. The aspirant having gathered from his sponsor the information which he had sought regarding the mission and the characteristics of the true physician, and the aims of the profession of medicine, would be likely to make special inquiries concerning the medical teachers, the schools, and the students of the past and present. In that case the sponsor would probably begin by suggest- ing that a rapid glance be cast at some of the medical myths of remote antiquity; at the temple schools under priestly conduct; at the Crotona school of philosophy and medicine; at the Hippocratic school whence began the evolution of the medical student; at the Alexandrian school; and at the Salernian and other schools of the middle ages, as a preliminary step to the inquiry respect- ing the teachers, the schools, and the students of the 35 MORAL PHILOSOPHY OF MEDICINE eighteenth, nineteenth, and twentieth centuries. In all likelihood his discourse would be substantially as follows: i. The medical myths of the Egyptians or of other ancient nations scarcely need any notice, since they give very little more information than those of the Greeks who borrowed nearly all of them and added to the list their own domestic legends; the earliest of which being about Melampus (1526 B.C.). This first medicine man, men- tioned in medical biography, does not appear to have instructed others than members of his own family, nor to have left any trace of the source whence he had ob- tained his knowledge of the art to which he united vati- cination. He was supposed to have won high repute in Argos by'curing of madness the daughters of King Pro- etus, by means of hellebore purgatives, warm baths and incantations. The fable then tells of Chiron the Centaur (1270, B.C.), and celebrates him as horse-doctor, medicine-man, teacher of bits of surgery, and instructor of Theseus, Amphiaraus, Castor, Achilles, and the renowned /Esculapius father of Machaon and Podalyrius the fighting physicians at the siege of Troy. 2. The ancient temples, serving in part for the reception and treatment of the sick but not for their prolonged lodgement as in modern hospitals, were the primitive schools of medicine in which the chief priests obtained some crude notions of disease^which they imparted to other priests or let them gather what they could from the "sacred book." None but the full-fledged priests were 36 TEACHERS, SCHOOLS AND STUDENTS practisers in these temples, these real dispensaries, out- side of which they saw no patients. 3. The Crotona school of philosophy and medicine, founded about 529 B.C. by Pythagoras, took the first departure from the custom of combining priestly and medical offices by admitting laymen to be instructed in medicine as well as in philosophy. From this school went forth men of much ability tinctured, however, with the master's fanciful notions. Empedocles (504, B.C.), and Alemaeon (500, B.C.), were among the votaries of the medical doctrines of that school, which afterward turned loose upon the world hosts of itinerant speculative phil- osophers, essaying to be physicians but burdened with nice hypotheses and lacking in practical skill for the treatment of disease. 4. Prior to the Hippocratic era (460, B.C.), it is clear from the foregoing, that there were no medical students properly so called; that is to say, men devoted to the study of the art of medicine with the fixed purpose of making its practice their sole occupation. That great reformer, who had obtained the rudiments of his vast medical knowledge in the /Esculapian temple of Cos, that true founder of rational medicine, had divorced the noble art from speculative philosophy and from priestly offices by taking as pupils young men who, under oath and stipulation, agreed to make the study and practice of medical art their profession and to engage in no other work. From this began the real evolution of the medical student. But the pupil had a single instructor, for there 37 MORAL PHILOSOPHY OF MEDICINE was not then what is now called a faculty composed of professors in the several branches of medicine, the one master teaching his disciples the whole art of physic. This sort of teaching was not uncommon even as lately as the first half of the nineteenth century. 5. The Alexandrian school of medicine, established through Ptolemyan munificence, and equipped with a regular corps of able professors engaged in teaching great numbers of domestic and foreign students, produced the accomplished, masterly Herophilus, Erasistratus and Galen, besides many other learned physicians who went forth into the world promulgating sound doctrines, doing good, and honoring their alma mater. The glorious school continued to flourish long after the fall of Alexandria in 640, A.D. 6. The Salernian school, founded in the eighth and closed early in the nineteenth century, also had a regu- lar corps of professors, ten in number. The studies com- prised the therapeutics of Galen, the beginning of the first canon of Avicenna, and the aphorisms of Hippocrates. The candidates for the degree of Doctor of Medicine were required to be at least twenty-one years of age and to have studied medicine under the guidance of learned pro- fessors for seven years. But to be received as surgeons they were obliged to spend an additional year in the study of anatomy. Another exaction was that each candidate should, on admission, take an oath of confor- mity to the laws of the school. A book was then handed to him, a ring placed on his left annular finger, and a crown 38 TEACHERS, SCHOOLS AND STUDENTS of laurel on his head. He was then wished God speed with a kiss of peace. Many of the students of that famous school attained great renown as physicians. Among them were Con- stantine of Carthage, better known as the African; Theo- dore, Archbishop of Canterbury; Wigart, Bishop of Hilde- sheim; Cuthbert, the English monk; John of Ravenna; Gerbert, afterward Pope Sylvester IL; John the Milan- ese, author of the Regimen Sanitatis Salerni; Gilles de Corbeil; and hosts of other clerico-medical celebrities. One of Gerbert's most distinguished students was Fulbert who became Bishop of Chartres and died in 1028. He practised and taught medicine with great success, and had among his pupils Peter of Chartres, Hildier, Goisbert, and John of Chartres physician to Henry 1. of France; all attaining celebrity in the medical art. 7. From the tenth to the fifteenth century, the union of priestly and medical offices was invariably exacted by the French schools all of which were episcopal or monas- tic; and for a very long time after laymen had been admitted as students of medicine, the priests continued to practice the art despite four forbidding decrees of church councils. The fifth and final decree, prohibiting them from entering upon the study or practice of medi- cine, did not take effect until about the middle of the eighteenth century. It was then that great teachers began to attract crowds of laymen as medical students, and that the continental schools offered the most abun- dant advantages to their pupils. 39 MORAL PHILOSOPHY OF MEDICINE Modern teachers, schools, and students of medicine although arising simultaneously in different countries, during the eighteenth century, had little effect in keeping the young from seeking knowledge in other lands than their own. Thus the Italian, French, Dutch, Austrian, and German universities long continued to attract students and physicians, destined to become teachers in their own country. English students in particular were wont to visit foreign lands either to begin or to complete their medical education. These itinerant students fol- lowed the example of Linacre who was graduated at Padua before taking his M.D. degree at Oxford; of Harvey who, after travelling in Germany and France, became the faithful disciple of the great Fabrizzio d'Acquapendente at the Padua school where he received his degree of M.D. when twenty-four years of age; of Sydenham who, after leaving Oxford went to Montpellier for more light; and of Mead who took his doctorate at Padua. Afterward Huxam, Pringle, Monro, Rutherford, Sinclair, Plummer, and others from Britain entered the Leyden school as pupils of the renowned Boerhaave. This English fashion of going abroad to complete medical studies lasted very many years notwithstanding the advantages offered by the hospitals of London and by the eminent men who taught medicine so well in these vast institutions, in the universities of Oxford and Cambridge, and in the great school of Edinburgh founded by Monro. Young American physicians also have long been in the habit of continuing their studies in European cities, chiefly Leyden, Vienna, 40 TEACHERS, SCHOOLS AND STUDENTS Berlin, Paris, London, and Edinburgh; returning home to become teachers. On the modern Parisian school of medicine, a few re- marks may be of interest to the American student. The effects of the labors of Petit, of Lapeyronie, and of other broad-minded physicians toward a stable organization of the modern school of Paris began to be felt, in the second half of the eighteenth century, when the illustrious Desault was drawing hosts of students eager to profit by his exceL lent teaching in anatomy and surgery. It was this great and good man's devotion to science together with his earnestness as a teacher that won the warm friendship, admiration and emulation of the young pupil Bichat and inspired him and others with his true love of knowledge and with the fullness of his zeal for original investigation which was followed by such great discoveries in patho- anatomy and practical medicine and surgery. These and other gifted laborers and masters soon attracted crowds of enthusiastic disciples from all parts of Europe and placed the school of medicine on a sound footing; and thus eventually made Paris the greatest medical center of the world. The present Faculty consists of thirty-seven pro- fessors and forty adjunct professors. The curriculum comprises some branches not generally taught in Ameri- can schools, as medical natural history, hygiene, legal medicine, the history of medicine, etc. Four years of study are exacted, and on the final examination the suc- cessful candidate receives his University diploma which however, does not entitle him to practise medicine, to do 41 MORAL PHILOSOPHY OF MEDICINE which he must obtain the State diploma conferred only on the French citizen. This State diploma, in effect, is the same as the license granted to graduates in medicine by American State Examining Boards. Of the early teaching in America, Doctor Thatcher, in his "Medical Biography," said that the first course of instruction was in the form of lectures on anatomy deliv- ered by Dr. Hunter, a Scotch physician, at Newport, R. 1., in the years 1754-5-6, and that the next, comprising anatomy, with dissections,* and obstetrics, was under- taken, in Philadelphia in 1762, by Dr. Shippen who was joined, in 1765, by Dr. Morgan to form a regular school of medicine where they lectured, the one on anatomy, the other on the institutes of medicine, until 1768 when Dr. Kuhn was appointed to the chair of botany. Finally, in 1769, Dr. Rush was chosen as professor of chemistry. Two years thereafter, the school became the medical department of the University of Pennsylvania. In New York, said Dr. Thatcher, "it was not till 1768 that a medical establishment was effected and organized; in which were united the learning and abilities of Doctors Clossy, Bard, Jones, Middleton, Smith, and Tennent, by whom lectures on the several branches were delivered. This school was connected with King's, now Columbia College, where in 1769, the degree of Bachelor in medi- cine was conferred upon Samuel Kissam and Robert * Doctor Thatcher, in his "Medical Biography," says that Dr Middleton with Dr. John Bard, in 1750, dissected a human body and injected the blood vessels, which was the first attempt of the kind on medical record in America. 42 TEACHERS, SCHOOLS AND STUDENTS Tucker. Tn 1770 the degree of Doctor in medicine was conferred upon the last-mentioned gentleman, and in May of the succeeding year, the same degree was con- ferred upon the former.' These were the first instances of medical degrees conferred in America, being a short time before those which were given at Philadelphia in the same year." Dr. Thatcher gave the following statement of the several medical institutions in the United States, with the date of their respective organization, and the number of students attending the lectures in 1825-6: University of Pennsylvania '7^5 Students 480 Medical School of New York 1768 196 Medical School of Harvard College . . . . 1782 130 Medical School of Dartmouth College >798 80 College of Medicine of Maryland 1807 215 Coll, of Phys, and Surg. West Dist., State of N. Y. 1812 120 Medical School of Yale College 1813 82 Medical College of Ohio 1818 22 Vermont Academy of Medicine 1818 124 Medical School of Transylvania 1819 235 Medical School of Maine 1820 60 Medical School of Brown University 1821 40 Med. School of the Univ, of Vermont 1822 42 Berkshire Medical School 1822 94 Med. Coll, of South Carolina 1824 5° Med. School of Jefferson College .... 1824 Columbia Coll. District of Columbia 1824 Medical School of Auburn 1825 Med. School of the Valley of Virginia 1826 Rutgers Medical College 1826 ■53 Although nine of these twenty medical schools enu- merated by Dr. Thatcher have long since been closed, the multiplication of schools of medicine continued during 43 MORAL PHILOSOPHY OF MEDICINE the second and third quarters of the nineteenth century, and before the end of the century about two-thirds of the states in the Union possessed medical colleges, some of them three, four, six, and seven, many of which were proprietary institutions not identified with universities. In general they were ill-equipped in almost every essen- tial particular. The term of lectures rarely exceeded six- teen weeks annually; only two years of study being required for graduation. The final examinations were so easy that even the unfittest passed successfully! With few exceptions, the graduates were practically illiterate and otherwise unqualified to belong to an honorable pro- fession. In some states licence to practice medicine was granted to persons who had never entered a medical college; and until the last three decades there was no law to forbid any individual from attaching the title of Doctor to his name, or from practising medicine. In an article on medical education which appeared in the Journal of American Medical Association, August 13, 1904, is a statement to the effect that there were in thirty- seven states and territories, one hundred and sixty-six medical colleges of different kinds, and that, of these one hundred and sixty-six colleges, sixty-six of the regular schools had a university connection or affiliation. Ten states had each one college, the others, two, four, seven, nine, and so up to sixteen; the total number of attending students being 26,138 and of graduates 5747. May the happy time come when, in each state, there will be but one university with its single medical school! 44 TEACHERS, SCHOOLS AND STUDENTS Great teachers make great schools, and only those schools attain eminence that are equipped with instructors who, by their sound moral principles, unflagging devotion to science, virile energy, practical skill, extensive lore, rare eloquence, and masterly gift to impart information, are able to stimulate appetite for the acquirement of knowl- edge and to attract many pupils and inspire them with enthusiasm and emulation. The greatest schools have ever been those whose teachers were the most accom- plished and whose pupils had become pre-eminent in their profession. The Padua school was aggrandised by its illustrious professors, foremost of whom was that pro- found anatomist and surgeon Fabrizzio, the master of Harvey. The Leyden school was made famous through the learning and scientific fascinations of Ruysch and of Boerhaave who were the instructors of so many men that became great masters in medicine. The Edinburgh school was great from the beginning by the excellence of its faculty whose following consisted of many students destined to be conspicuous in the healing art. And Lon- don was celebrated as a medical center by the galaxy of luminaries of which John Hunter was the brightest. And Paris became great medically on the advent of the renowned Desault. And so, in America, the illustrious men who had won their laurels as physicians and were able to draw large numbers of disciples by their sound and admirable teachings, gave repute and even greatness to the colleges they had founded or to those which sought them as teachers. Thus Shippen, Morgan, Kuhn, Rush, 45 MORAL PHILOSOPHY OF MEDICINE Physic, Hosack, Warren, Nathan Smith, Mott, Francis, Beck, Crosby, March, Hamilton, Leidy, Dickson, Gross, Flint, Clark, Dalton, and other able teachers, were the chief attractions in the domestic schools of medicine. The medical students of the last quarter of the nine- teenth century, in the United States, seem to have dis- played more earnestness and efficiency than those of the second and third quarters. Dr. Holmes' "young man John's'' little peculiarities surely were not comparable in waywardness to Dickens' Bob Sawyer and Ben. Allen who are pictured as arch types of the most dissolute, debauched, and reckless "saw-bones"-fortunately long extinct horrid maculations of the species designated "average students." The American students, about whom the fourth Dr. Austin Flint has written so well from long experience as a teacher, are, in fair proportion, truly faithful laborers in the field of medicine. He places them in three categories: i. the good, 2. the average, and 3. the poor student. 1. "The good students," he says, "exercise a great influence over the general opinion of the class. They practically keep themselves apart from the others, and have nothing in common with those classed as 'poor stu- dents.' Their habits are almost invariably good; they are present at all the prescribed exercises; they dissect together .... and form little clubs among them- selves for quizzing and mutual improvement. When one of this little coterie is forced to miss a day's attendance, his fellow-students aid him in filling the gap. Their 46 TEACHERS, SCHOOLS AND STUDENTS amusements during the session are few, and the work they do is enormous. Their verdict upon the ability and efficiency of individual teachers is accepted by the class as final. They usually take under their protection cer- tain of their juniors, who assume their position in the class when they have been graduated. The 'good stu- dents' pass their collegiate life in an atmosphere of medi- cine. Medicine is the only subject which occupies their thoughts and conversation. Generosity of students of this class toward each other is almost invariable. . . . Those who had been graduated in arts usually were superior to those of less thorough preliminary education." 2. "The 'average student' here is about the same as the average student elsewhere. He does not attain the rank of the 'good student,' for many and various reasons. Many 'average students' are sadly deficient in mental training, even if their preliminary education is up to the proper standard. Many students do not know how to study. Many are careless and have no fixed purpose, no enthusiasm, no capacity for consecutive mental effort. Some are bright, quick, and apt, but indolent. They may be 'crammed' for their examinations, and thus escape from the class of 'poor students,' but their knowl- edge is superficial and indefinite." 3. "The 'poor student' is a poor creature indeed. Those who are but little above the unfortunate candidates who fail in their examinations, seldom do any credit to themselves or to the profession, although there are some rare exceptions." 47 MORAL PHILOSOPHY OF MEDICINE The future exaction of a higher standard of acquire- ments for matriculation will surely have the effect of eliminating all applicants likely to be "poor students," and of reducing the number of those classed as "average students." The probable requirements for medical studentship at no very distant date in this twentieth century now deserve some consideration, beginning with a query from the aspirant and following it by an endeavor to make a con- cise reply to the important question. When the aspirant asks whether ''a matriculation ex- amination is exacted of the applicant?" The answer from his sponsor is likely to be as follows: Although, as a gen- eral rule, such an examination has not been required, the time has arrived for all the American universities to exact it from every applicant for matriculation in the medical schools. The great advances in the science of medicine during the past twenty years, demand of its future votaries a much more rigid preliminary training than heretofore, and other high qualifications will be exacted of the postu- lant besides vigorous health, an ample and clear intellect, a well-balanced mind, a good memory, keen discretion, good sense, good nature, unflagging industry, much energy, steadfast perseverance, self-reliance, love of study, special aptitude, commendable ambition, a lofty sense of honor, moral principles above reproach, delicate sensibili- ties, refined tastes, and the keenest appreciation of human suffering. In the very near future, no young gentleman, unless possessed of these qualities, will be encouraged to 48 TEACHERS, SCHOOLS AND STUDENTS aspire to membership in the honorable corps of medical students. Even the fortunate must have undergone a thorough preparatory training comprising not only his collegiate education ending in the reception of the degree of Bachelor of Arts, but studies in natural science, bio- chemics, and such other subjects as may be subservient to medical investigation. In addition to these require- ments, it is very probable that he will be subjected to a physical and mental examination with the several objects of determining his power of enduring the arduous labors, the vicissitudes, and the privations incident to the life of the student and future practising physician; of ascertain- ing the condition of his sense organs; of estimating his mental capacity; and of judging of his aptitude for con- tinuous hard study. Since an entrance examination is obligatory in the arts department of every university, and since a physical as well as mental examination is required for admission to the national military and naval academies, there is no good reason why similar examinations should not be exacted in the medical school of a university. An able writer on the requirements of a sound medical education said: "To suppose that general attainments in knowledge, and even a predilection for its finer literature, have a tendency to disqualify or enfeeble the medical man, is to avow an ignorance of the character and private his- tory of the most distinguished men who in every age and country have improved and elevated that profession. Variety of knowledge was never seen to encumber the possessor; on the contrary it prepares an ampler space and 49 MORAL PHILOSOPHY OF MEDICINE a firmer footing for all that is to come after. In the numberless and unexpected emergencies which occur in the relief of diseases of the body and of the mind, in the ever-varying combinations of causes and of character which present themselves, an almost universal acquain- tance with nature and art would seem to be demanded. The power of making good observations, a retentive mem- ory, a fixed attention, and the habit of generalising, are among the most important qualities of the physician, and these can only be acquired or strengthened by an early and extensive intellectual education." That the great physicians of past times were profound scholars is shown by their writings which have survived so many centuries chiefly because of their clearness in the depiction of morbid conditions, and of the purity of their diction. The masterly books of Hippocrates so justly celebrated for conciseness of language, and the elegant Latin of Celsus, and the pure Attic of Galen are justly ranked as marvels of literary composition. Many more might be cited among the illustrious ancient medical wri- ters, and as many among those of the first half of the nineteenth century in France, Germany, England, and America, whose works are too little perused, unfortunately for the present generation that pays such scant attention to medical history and biography, or to the cultivation of classic lore. The nation will have to look among the young men who are now aspiring to medical honors for subjects worthy of the laurel wreath. It has been said with truth that the most accomplished 50 TEACHERS, SCHOOLS AND STUDENTS medical scholars and best writers have generally been the cleverest practical physicians, and that no man, in this twentieth century, is likely to attain eminence who was not a classical scholar before he began the study of medi- cine. The later revival of learning and of classic litera- ture was due, in no small measure, to those medical scholars who effected so well the translation of the works of Hippocrates, Celsus, Galen, and of other ancient writers on medicine. . Only through the highest standard of requirements can an effective medical army be organized for perpetual struggle with disease. The recruits will thus be of a better sort than ever before and more suitably equipped for coping with the enemy. Then, with a reorganized grand army of the republic of medicine on the right basis, there will be, during this twentieth century, an era in the march of the science unparalleled in greatness, for, the scores of prior centuries of labor and strife after knowledge have served mainly as a long recognisance in force to find the devious ways of man's dread and insidious enemy disease, in order that all newly devised engines, designed to relieve suffering and prolong life, may be effectively used in this warfare which will be without end. The first and second conferences, together with the present, constitute a much condensed statement of a score of conversations such as are profitably held between his sponsor and the aspirant, who shall have learned, from the replies to his queries, something of the history and the nature of the profession, of the mission of the true 51 MORAL PHILOSOPHY OF MEDICINE physician, and of the fact that great physicians were not only profound scholars but accomplished anatomists. So he will naturally conclude to devote much of his time to the study of the structure and functions of the body. After these preliminary instructions, derived from replies to his queries, the aspirant will be ready to enter his wider field of labor with seeing eyes, hearing ears, and clear perceptions; well prepared to appreciate the teach- ings of his masters in the medical school of which he shall be a pupil. 52 IV THE MATRICULATED STUDENT Answers to the matriculate's queries-Note taking; its value as an aid to memory, as a guide to reading, as an assurance of accuracy in.debate, and as a serviceable adjunct in learning the art of writing with precision and clearness-The attend- ance of lectures on other than medical subjects-The Class Society-What the student should read besides medical works-Physical exercise, diet, sleep, and social duties of students-Relations of students to their teachers and to each other. The aspirant, after presenting to the Dean of the Faculty suitable credentials, obtained from his sponsor, is admitted to the entrance examination which, if he pass success- fully, will entitle him to be received as a matriculate and to become a member of the first year class in the school of medicine. As a skilled inquirer, he begins by asking how much time and attention may be given ■profitably to the annotation of medical lectures? He is then told, by all means, to cultivate the habit of taking notes, in his own words as much as possible, of such salient points in his masters' lectures as might be required for future reference, and devote a reasonable time to their revision. He is also told that such anno- tions will not only serve to impress upon his mind the 53 MORAL PHILOSOPHY OF MEDICINE wise utterances of the learned, help their retention in his memory, guide him in his reading, make him accurate in debate, and be valuable to him for use in the far future, but will be of very much service toward the beginning of his training in the rare art of writing with precision, brev- ity, and clearness; bearing in mind the sapient Baconian saying: "Reading maketh a full man, conference a ready man, and writing an exact man." He is further told that such industry will assuredly be crowned with a high reward; and the respondent perhaps cites examples such as the following: Doctor Parry, one of the lights of English medicine in the second half of the eighteenth century, said that dur- ing the first twelve or fourteen years of his professional life, he had recorded almost every case which had occurred to him either in private practice or in the chief conduct of an extensive charity. One of the most instructive clinical teachers of America began, early in his professional career, the anno- tation of nearly all the cases of disease that came under his care privately or in hospitals, and continued to do so and to make the best use of those notes, in his lectures and writings, for fifty years when they had filled more than twenty large quarto volumes of several hundred pages each. These admirable examples are well worth follow- ing by all who expect to contribute information for the benefit of sufferers. Should the student attend lectures on other than medical subjects? 54 THE MATRICULATED STUDENT Yes, from time to time, for then he will listen with pleasing diversion to entertaining discourses on different subjects of general interest, serving to brush off those tangled cerebral cobwebs whose accumulation hinders the intellectual expansion of hard students devoted too exclu- sively to medicine. Such relaxation lifts their thoughts from narrow mental ruts, and is otherwise of much profit to them during college life. But even afterward when launched in the practice of medicine, they will feel the good effect of the early habit of extending the boundaries of their fields of investigation, and admit that every man of understanding should acquire some knowledge of many things that do not strictly pertain to his profession. How- ever, at first, it will be wise, on the part of students as well as of young physicians, to attend chiefly lectures on subjects, in science, art and letters, that may be sub- servient to their professional purposes, and only occa- sionally those which afford them other kinds of entertain- ment. The more general information the medical man possesses, the more complete he is and the better fitted for the exercise of his calling. But he should not dive too deeply into extraneous waters in search of those pearls of truth which have too distant relations to his profession. It is almost as bad for a physician to know nothing but medicine as to know everything but medi- cine. In either case he would be in danger of losing his clients or of forfeiting their confidence and respect. So he should exercise some judgment in the selection of proper kinds of extraneous knowledge which, used with 55 MORAL PHILOSOPHY OF MEDICINE due discretion, cannot fail to be helpful to him not only in his professional offices but in his worldly relations. This is remindful of what Dr. Baillie's biographer said of some witticism between him and Dr. Gregory. "A few years before his death, during a visit which the late Professor Gregory of Edinburgh made to London, these two eminent countrymen, equally distinguished in their respective departments, conversed on several occasions; and the judgment they jocosely passed upon each other was expressed in the following manner: 'Baillie,' said the accomplished and classical professor, 'knows nothing but physic.' 'Gregory,' exclaimed the skilful and experienced London physician, 'seems to me to know everything but physic.'" However, the truth is that both men were clever physicians and Dr. Baillie was by no means deficient in letters and general knowledge. IV hen should the newcomer join the Class Society? The student should apply for membership of the society as soon as practicable after matriculation; and then asso- ciate himself with some of his fellows to form a section of the class society for mutual aid in study and for other laudable purposes; each section forming its own quiz and perhaps employing a quiz-master. Such societies must exert a very great and good influence on their members throughout life. Periodic reunions of the whole class for conference on subjects of professional interest cannot fail to be advantageous to all the members. The discussions likely to occur on these occasions would constitute a wholesome exercise in the art of speaking while ''standing 56 THE MATRICULATED STUDENT on the hind legs," as felicitously expressed by an eminent teacher. Many persons who speak well enough, logically and naturally in the sitting posture, lose ideas, words, and even voice the moment they rise to take part in debate. Therefore, it is essential that the student early learn to be confident in his power to make himself heard and understood, and so to be a successful debater; otherwise, he will not be a ready and lucid extemporaneous speaker howsoever well he may know his subject. "Conference maketh a ready man." To be a ready man on his hinder legs requires persevering practice. One example will suffice: During his pupilage, the great Doctor Gooch attended the Edinburgh Royal Infirmary; and though in the first year he rarely missed a lecture, he found time to be a regular attendant at society meetings where he took an active part in the discussions and expressed himself with only "tolerable facility." He spoke much better in the second year, but toward the close of the third year became one of the foremost debaters. He never affected to declaim but was a close reasoner, and an unsparing op- ponent. On one occasion, says his biographer, when " a medical coxcomb had written a paper as full of preten- sion as it was void of merit, Gooch so severely handled him in the debate that he burst into tears and left the meeting." This last part of the example is one which, however, the student or the young physician of these times should not think of following. Never should he transgress the amenities of legitimate debate by wound- 57 MORAL PHILOSOPHY OF MEDICINE ing the sensibilities of his opponent. He should be satis- fied to refute, in the most considerate tone, the erroneous views stated, and endeavor to find points in the antago- nist's argument that are praiseworthy, in order to com- mend them, which he should do without ostentation and without the least semblance of patronage. To the question what should the student read besides medi- cal works during and after college life? The answer is that in addition to the text-books and philosophical essays prescribed by his teachers, he should peruse, for relaxation, those works of fiction only which are known to possess a high order of literary merit and which at the same time picture well the many phases of human nature. Such reading will not only afford him diversion and entertainment, but will be restful and expansive to his mind and fit him all the better to appre- ciate the facts and comments contained in his text books or stated in medical lectures. " Reading maketh a full man." Sir Richard Blackmore, wishing to begin the study of medicine, asked Sydenham what books he should read to qualify him for practice. "Read Don Quixote," re- plied Sydenham, "it is a very good book, I read it still." Doctor Johnson suggested that Sydenham might have meant, seriously or in jest, to insinuate that Blackmore "was not adapted by nature to the study of physic, and that whether he should read Cervantes or Hippocrates, he would be equally unqualified for, and unsuccessful in, practice." Doubtless Sydenham had read Don Quixote for diversion and as an aid to the study of the follies of 58 THE MATRICULATED STUDENT men, so it is not unlikely that he should have recom- mended the book to the neophyte with the idea that its perusal might dissuade him from attempting to tilt against the gigantic problems of medicine. Assuredly there are two works of fiction that all students and young physi- cians should not fail to read, at least twice, for diversion and instruction. One of these is this very Don Quixote of Cervantes, and the other is the Gil Blas of Le Sage. The first gives a true picture of the visionary man and his vagaries, suggests means to check or subvert conceit and youthful Quixotism, and teaches much through the almost countless proverbs that so incessantly flow from the Don and his faithful Sancho. The second, a highly artistic portrayal of human life of the past and present, is a val- uable guide against moral pitfalls. The pure diction, the charming simplicity of style in the narration of Santil- lana's adventures, the sparkling wit displayed throughout the work, the wholesome lessons it teaches, the elegant French of the original, and the excellent Spanish used in the translation, delight both the moralist and the scholar; each reading of this masterpiece revealing some brilliant witticism unperceived before or something more to add to the stock of worldly and literary lore of the reader. Unfortunately many of the beauties of the work are lost in the English translation by Smollett. Still another work of fiction, entertaining alike to the young and the old, is the "History of Zadig" which should be read on account of its wonderful depiction of human nature as it ever was and is likely to be always. But there is a par- 59 MORAL PHILOSOPHY OF MEDICINE ticular passage in this exquisite work of the eighteenth century philosopher which should induce all men of sci- ence to study it, and that is the admirable statement of Zadig's marvelous power of discrimination. Professor Huxley was perhaps the first modern English writer to call general attention to the "method of Zadig," and to its great value in scientific investigation. However, this inductive method is traceable to Hippocrates who had bequeathed it to the medical profession whose members have employed it ever since in their investigations. "And out of olde bokis, in good faithe, comith all this newe science that menne learn," sayeth Chaucer. Next in order for constant, profitable, and entertain- ing reading are the sublime philosophic works of Shake- speare, also Bacon's essays. The Holy Bible, and the works of Milton, besides their sound moral teachings are of great value to the scholar for the selection of words, for simplicity of style, and for many other objects. The true student never shelves his chief Greek and Latin classics. To keep pace with the scientific advances of this age, the student and young physician should be con- stant readers of the best lay and medical magazines, besides special treatises. Thus equipped with the richest literary and medical lore, they will be sure to occupy a high position in and out of the profession. So much has been said of intellectual exercise that the stu- dent is naturally desirous to know what kind of physical exercise he should take? The necessarily sedentary life of the medical student 60 THE MATRICULATED STUDENT is a sufficient inducement for him to make the right sort of physical exercise a part of his professional training. He has not the leisure to continue his former heavy ath- letics nor would it be wise to do so; great physical exer- tion and its consequent fatigue being as little conducive to profitable mental labor as continuous, unrelaxed study is to health of body; therefore, in both moderation is essential. He should abstain from all those gymnastic exercises that are likely to harden or otherwise mar his hands, and so, blunt the tactile sensibility. He knows too, that the slightest epidermic abrasion would be a nidus for the lodgement of some laboratory irritant or for the pullullation of infective organisms. His aesthetic instinct leads him to keep his hands and finger nails shapely, sightly, white, and in the best condition for the maintenance of a delicate sense of touch so indispensable to the physician. The physical exercises most suitable to the medical stu- dent are: fencing, to give him quickness of sight and action; light calisthenics, for general muscular tonicity and chest expansion; dancing, for gracefulness and for quickening the blood circulation; brisk walking, for relief of the sluggish circulation in the lower limbs incident to long confinement in the sitting posture; horseback riding, for action of nearly the whole muscular system. Such for him, are among the best of physical exercises without which he is likely to become a victim to gastric and intestinal disturbances and other ails unfitting him for the advantageous pursuance of his studies. 61 MORAL PHILOSOPHY OF MEDICINE As he might become a teacher, he should take particu- lar pains to exercise his lungs and his vocal apparatus under good masters who would instruct him in the mys- teries of oratory. The early cultivation of oratorical art is unquestionably of much importance to teachers, for through the power of aural fascination they can generally render a dry subject so attractive and entertaining as to fix the attention of all listeners. Much of the matter in medicine has lent itself to the triumphs of eloquence of those great teachers who have lectured to large audiences of students eager to drink deeply of the wise lore, rich in happy illustrations and dispensed so charmingly, to their great profit, in vivid, elegant, and forcible language uttered in honeyed tones. Judging from the writings of the divine Hippocrates, his oral lessons must have been as eloquent as instructive. The vast influence he doubtless exerted on his disciples was probably due in great part to his manner of teaching, for his was a great age of oratory. In cultivating the art of speaking, the student will do well to keep constantly in mind the words of Hamlet to the players. "Speak the speech, I pray you, as I pro- nounced it to you, trippingly on the tongue: but if you mouth it, as many of you players do, I had as lief the town- crier spoke my lines. Nor do not saw the air too much with your hand, thus, but use all gently; for in the very torrent, tempest, and, as I may say, the whirlwind of passion, you must acquire and beget a temperance that may give it smoothness." The diet question is one of no little importance to the 62 THE MATRICULATED STUDENT student who can do good work only on a generous, varied, and wholesome dietary. Although, in youth, quantity is ordinarily more regarded than quality, he is wise who pays proper attention to rational alimentation and to the nutritive properties and digestibility of the different food stuffs, and early begins to cultivate his gustative sense, for, a right valuation of edibles gives him authority in his prescription of the diet of invalids. He then knows what to prescribe or to proscribe, and when to direct absti- nence or to check excess. Beverages other than indispen- sable water-which constitutes nearly three-fourths of his body's weight-than milk or the infusion of tea or coffee, are not generally necessary. There is in youth quite enough buoyancy and merriment without the aid of artificial stimulation. Small beer and light wines should be the utmost limitation of his most ardent beverages. What of tobacco, asks a jolly smoker? The incessant howlings and growlings of all the anti- tobacconists in this wide world will never deter the stu- dent from enjoying his cigar, cigarette or pipe as he should; nor will the deadly poisons tobacco is said to contain frighten him into abandoning its use, for he is fully impressed with the solemn truth that tobacco- smoking is not a vice but a virtue; that, in moderation it is a wholesome peristaltic persuader; that it has the effect of retarding the development of mischievous bac- teria; that its disinfecting properties render its free use essential in the dissecting room; that it is a soothing, safe, and trusty companion in solitude; that it is one of 63 MORAL PHILOSOPHY OF MEDICINE the chief intellectual feeders of poets, philosophers and physicians; that its disprisal has come generally from those who have used it to excess: from the idiosyncratic, and from others who have judged rashly whout having ever tried the effects of the delightful weed; that the sacred herb is indigenous of America; that the habit of smoking it is of American origin, as attested by Colum- bus, and therefore to be encouraged; and that the dili- gent student is naturally a good smoker and consequently an excellent fellow. But he does not foster the use of tobacco in the form of snuff because he regards snuffing as inelegant and as having the effect of blunting the olfactive sense. The chewing of tobacco, he thinks, is likewise objectionable and uncleanly; imparting to the breath an offensive odor, and thus being unsuited to the physician, particularly at the bedside of the sick. A cynic, who did not make use of tobacco, once was heard to say that if he had ever regarded its use as a vice he would long before have taken to smoking cigars, but, believing it a virtue, he abstained. How much sleep does the student need? All physiosophists are agreed that of the twenty-four hours of the day, eight should be devoted to work; eight to physical exercise, relaxation and alimentation; and eight to sleep, and that not a moment should be taken from that needful rest of body and mind during the term of hardest study. How much time should the student devote to social duties? He should make his social intercourse a pleasing fea- 64 THE MATRICULATED STUDENT ture of the periods of relaxation from his studies and devote occasional evenings to such festal gatherings as may accord with his inclinations, and to the cultivation of the acquaintance of persons of refinement from whose conversation pleasure and instruction are derivable. Let him remember that during the hours passed in the society of ladies and gentlemen he should never "talk shop" or even speak of his studies. Conversations on things in general rather than on men in particular are always inoffensive and entertaining, and safely bear repetition. He should be on his guard when some well meaning per- son asks him about "the health of the city" or something else pertaining to medicine, and be ready with a simple answer, then stop and adroitly without offence, change the subject of conversation. These social relations are generally very beneficial to the good observer and afford him excellent opportunities to study peculiarities in the young and old. Some evenings may be passed very profitably with friends in listening to good music or in frequenting, in their company, places of amusement where he may wit- ness plays of a high order, and enjoy the performance of those great interpreters of masterly comedies or tragedies that picture so well the human nature of the past and present; and he will not fail to derive much intellectual and sensual benefit if he give an attentive mental ear to the exalted thoughts expressed in the purest language and uttered in the most charming elocution by their gifted exponents. 65 MORAL PHILOSOPHY OF MEDICINE An occasional evening is well spent in the company of fellow students for medical talk and tobacco-burning- after the manner of Doctor Holmes "young man John"- or in a sitting with a grave and reverend physician from whom the junior is wont to gather medical lore for use in the future. But the cultivation of friendly relations with an elder is the more profitable to the advanced student and the young physician. Men of superior mental con- stitution who aspire to professional honors generally end their youthful merry-making between the ages of twenty- eight and thirty when they fully realise the extent of their professional responsibilities. All pranks, all bois- terousness then vanish and new and more rational amuse- ments take their place which they occupy in permanence. After thirty years of age they begin to take life still more seriously and to manifest that becoming gravity which has no semblance of dullness, but, on proper occasions, listen with pleasure to such facetioe as do not border on buffoonery. Without levity they possess the cheerful- ness that becomes all men. In more mature years they are the medical counsellors and their advice is eagerly sought by their younger colleagues. In later life comes the fondness of retrospection. At this time the cultured physician loves to see his juniors and to encourage them to ply him with questions relating chiefly to the unwritten history of medical events in his early professional life, to his first experiences in practice, and to many things that are not in medical books, besides literary, historic and biographic questions. The young friend thus enjoys a 66 THE MATRICULATED STUDENT delightful evening while smoking a fragrant cigar with his philosophic mentor and listening to his wise saws. It is now opportune to say something of the relations of students to their teachers and to each other. To his teachers, who are the foster-parents of his develop- ing mental faculties, the relations of the student should be filial with sincere manifestations of love, respect, obedience and gratitude. By diligence in his studies and close attention to the lectures and laboratory instructions, he wins the approval of his sponsor and of his examiners under whose eyes he ever is, and of the good wishes of his teachers who then labor the harder for his advance- ment in recognition of his great assiduity and receptive- ness. So the result of his industry giving satisfaction to these teachers, he receives from them encouraging praise with more instruction, and is the greater gainer in the reciprocity. His relations to fellow-students being fraternal, slight misunderstandings are easily healed, whilst graver things may be referred to the class section for adjustment. The importance of the establishment of sections of the class society cannot be too highly estimated. The good effects of similar organizations have long been known, as exempli- fied by something like a class section which had a remark- able success, many years ago, in a European city where a few young men who had been bound in strong friend- ship, agreed to help each other throughout the period of their studies but who went much farther and stood together as one. The members of the little association 67 MORAL PHILOSOPHY OF MEDICINE labored so constantly, faithfully, ardently and loyally for each other during the several college terms, that all were graduated with honors; all served as hospital-internes; all began private practice under favorable auspices dur- ing the same year and were eminently successful; all con- tinued their allegiance to the organization; all received appointments as visiting physicians to the great hospitals; and all became professors in the grand school of medicine. Their unprecedented success and prosperity were due largely to this mutual assistance. One of the loyal con- fraternity died in the early part of his brilliant medical career, leaving a son who was cared for by the surviving members, and who, through their instructions and influ- ence became an eminent physician and professor in the great medical school. The section organisation is almost certain to effect the greatest good to its individual members if each section be true to its members, its members true to each other, fair to the members of all other sections, and faithful to the class society; while all are reverent to Alma Mater and loyal to the profession. At the end of his fourth collegiate year, the student goes before the Faculty for his final examination. Being successful he receives his degree and is ready to apply for appointment on the medical staff of some hospital. In the competitive examination for admission to the house-staff of hospitals, the members of the several sec- tions of the class society will need and will get much help from each other to secure due representation in these 68 THE MATRICULATED STUDENT hospitals where to begin the practice of medicine under the tutelage of members of the visiting staff who will be their new devoted masters to whom they should be loyal, obedient and respectful, and grateful too for their daily practical bedside instructions, and for many acts of paternal kindness. 69 V THE GRADUATE AS HOSPITAL-INTERNE Relations and obligations of hospital-internes to each other to members of the Medical Board, and to the lay officers- Reciprocity-Hospital discipline-The main forms of proce- dure to subserve the interests of patients and the efficiency of the medical staff-Criterion of conduct of members of the house-staff-Conduct of the medical officers in the operating room. On the eve of graduation, the good student, ambitious to secure the hospital internate, is dreaming, half awake, of his chances of passing successfully the competitive examination which is to determine admission to the corps of internes. Notwithstanding his long preparation for this examination with the aid of some of his fellows, his anxiety rises to fervent heat when he considers how very many are competing out of the great numbers of stu- dents who are equally desirous to enter the medical staffs of the hospitals. He is deeply saddened by the thought that he may be among the disappointed who are to be deprived of the privileges and opportunities afforded to the few successful candidates, and endeavors to be con- soled by the hope that, in the event of failure, he may still be able to enjoy the privileges of bedside study of disease through the good will of his friends who are ad- 70 GRADUATE AS HOSPITAL-INTERNE mitted. But to his delight he is successful and ready and glad to grant to his less fortunate friends all the privileges he had so much desired for himself. Admitted to the grade of junior assistant, he soon finds many things to learn, not only in practical medicine, but about his various obligations as member of the staff; and desires to be told of the exact nature of these obligations for they are not all contained in the printed rules and regulations of the institution. Hence this conference which is in- tended to give him a brief statement of the more useful rules of conduct. The relations, obligations, and observances of young hospital-physicians are of so many kinds, that a few only of those which are of greater import will be named at present. The graduate, realising his obligations to his colleagues, to his teachers in the Medical Board, and to the other officers of the hospital, is not likely to forget the impression he received, from his early studies in moral philosophy, that obligations must necessarily be reciprocal, and that, therefore, his colleagues, his teachers, and the other officers of the hospital are as much bound to him as he is to them, as dependent upon him as he is upon them for the accomplishment of certain duties. He finds confirmation of these views in the sermon on the Mount, in the Hippocratic Oath, in the national system of medical morals, and in his own bodily functions. There is no better illustration of the obligation of reciprocity than that afforded by the human body whose organs are so interdependent that failure of one organ to yield its 71 MORAL PHILOSOPHY OF MEDICINE due service disturbs the apparatus of which it is a con- stituent part, and the disturbance of this apparatus re- acts injuriously upon the others and indeed upon the whole organism. The idea of this essential reciprocity, this general interdependence, in the actions of the divers parts of the body, which, however, is almost as old as medicine, is treated very ably, though facetiously, by the learned, keen-witted Rabelais in the last paragraph of the third chapter, and in the second, third, and fourth para- graphs of the fourth chapter of the third book of Panta- gruel on debtors and borrowers; taking his cue from /Esop's apologue of the dispute of the members and the stomach which was modernised and so admirably versified by the gifted fabulist, La Fontaine, who takes occasion to refer to Menenius Agrippa's happy application of this /Esopian apologue. The new member of the house-staff having asked to be told something of the particular rules of conduct by which to be governed in his relations to his colleagues, his teachers, and others; the replies are, in substance, as follows: His relations to fellow-internes should be fraternal, amicable, cordial, and harmonious, for he will often need their aid and counsel in his ministrations to the ills of some gravely afflicted sufferers. If then all be animated with the same zeal in the performance of duty and the observance of reciprocity, the general good will become the good of each who will always cheerfully give his help toward the promotion of the welfare of his fellows and to 72 GRADUATE AS HOSPITAL-INTERNE maintenance of mutual aid in studies, besides fostering the good-fellowship and enduring friendship so helpful at all times, so delightful in middle life, and such a bless- ing in old age. His relations to the members of the Medical Board, who are his new teachers and intellectual foster-parents, should be filial with manifestations of respect, obedience, and gratitude. By diligence in his daily labors and close attention to his duties and to the bedside instructions of these teachers he gains their warm approval, and the grateful appreciation of patients, as well as the regard of his colleagues. His relations to the lay officers of the hospital should be of such a nature as to inspire them with good will, with friendliness, and with a disposition and a readiness always to do their best for his well-being; and it will be often in his power to reciprocate by ministering to their ails, and by other acts of kindness. Some of the larger hospitals, consisting of several divisions, are necessarily equipped with as many separate visiting and house staffs. In former times, this circum- stance has often been the chief cause of an unpleasant and even offensive distance, and of an unbecoming rivalry between the different divisions; the members of one di- vision knowing or affecting to know little or nothing of members of another division, both sometimes lacking in the courtesies due to each other, and even to members of the visiting staff. These little miseries should not and, it is hoped, do not now exist. The exchange of civilities 73 MORAL PHILOSOPHY OF MEDICINE among the medical as well as between the medical and lay officers cannot fail to be conducive to good will, right understanding, and general contentment. In all social, official, and professional relations, the observance of due ceremony is always becoming. It "softens manners, expands affections, and dignifies conduct.'' Having entered the hospital for the faithful care of the sick and for the acquirement of knowledge, the young physician should make the best of his opportunities and do nothing likely to interfere with the accomplishment of these laudable objects. The nature of his conduct toward the patients, his colleagues, and others, will determine the character of his future professional relations and, in private life, he will be exactly what he was among his fellows at the hospital. Each division of some hospitals has its own particular house-staff consisting of a house-physician, a senior assistant, a junior assistant, an externe, and ambulance surgeon. This system has operated well during many years, as much for the good of patients as for the general discipline of the establishment the medical government of which is confided to the visiting-staff under whose instruc- tions the house-staff acts generally in harmony. However, troubles have sometimes arisen in the house-staff, but ordinarily of a trifling nature and soon remedied through the exercise of good sense and temper on the part of the house-physician. In the distant past, such minor vexa- tions have occasionally been due to the overzealousness and officiousness of the incoming junior assistant before he 74 GRADUATE AS HOSPITAL-INTERNE had been able to read the hospital regulations. A single example will suffice: In long gone-by days, the unsophisticated junior assist- ant, believing his bounden duty to be the expounding of the science and art of medicine to the whole staff of hos- pital physicians and the rest of the world, was wont to assume, at the bedside, a ludicrous attitude of profundity and, brimful of fiery enthusiasm with a vast overflow of theoretic lore and a roaring torrent of garrulity, would solemnly make known his diagnosis, and with much cir- cumstance give his views as to the treatment and the prognosis-all three wrong of course. The expression of so much wisdom met with no response save such significant smiles from his unwilling auditors as to cool his ardor, check his loquacity, and excite his anger which good man- ners induced him to suppress. The house-physician would forthwith, with a glance, turn the delinquent over to the senior assistant for indoctrination as to his duties. The senior would then begin by mildly suggesting to him, in a whisper, that a truly efficient junior should be a good silent listener who does as he is told and tries to learn something. This comical scene generally occurred but once in the life of the junior, for he realised that it is better to be "checked for silence than taxed for speech." The salutary lesson made of him a good senior assistant who learned his duty and performed it cheerfully and well. By all good managers of hospitals, the importance of looking after the sanitation of the habitations and the hygiene of the house-staffs and indeed of all the inmates, 75 MORAL PHILOSOPHY OF MEDICINE has, of late years, been fully realised. Greater attention than ever before is given to the housing of internes, to their dietary, and to the proper provision of bathing facili- ties and of outdoor physical exercise. These observances came to be regarded by the authorities as essential to the successful economic conduct and to the medical efficiency of public institutions, ever since their attention was called to the great mortality among hospital-internes from pre- ventable diseases contracted in the line of duty. The hospital-interne, howsoever strong in bodily health, often suffers grievous physical and mental fatigue from his onerous duties to the sick, and from his continuous study. Therefore he should not lose sight of the fact that the body of the hard worker requires rest and his mind diversion, both of which are best obtained in his own family circle away from the seat of his labors, or in some place of rational amusement. This course is generally encouraged by his masters of the visiting-staff. A former member of the house-staff of a large public institution asked some excellent questions pertaining to hospital discipline. Since the replies to those queries may be of use to the newly admitted, they will be given in the order of their asking. I. In hospital discipline, what are the main forms of pro- cedure which best subserve the interests of the patients, and the efficiency of the medical corps and of the attendants? Of some of the forms of procedure it may be said, that when a patient is admitted to a ward, he is assigned, with- out delay, to a numbered bed at the head of which is a 76 GRADUATE AS HOSPITAL-INTERNE card with his name, age, occupation, and the date of his admission thereon inscribed. It is then the duty of the ward attendant to minister to his comfort and immediate wants, and to assure himself that he is clean; if not, to cleanse him at once. On his part, if conscious, the patient is required to obey the directions of the attendant who is acting under the instructions of the house physician. When a case seems to need immediate medical aid, it is the im- perative duty of the attendant to promptly notify the house-physician. Sometimes the patient obstinately dis- obeys the injunctions of the attendant whose duty is then to report the case to the house-physician. A singular instance of this kind may be worth mentioning: Among the newly admitted patients to a hospital, many years ago, was a tall, gaunt, famished, unkempt, un- washed emulator of Crates the cynic, very much cleaner, however, in his speech than in his person, not being judged fit to retire to bed, fatigued as he was and suffering with some contusions from sundry blows and heavy falls caused by inco-ordinate muscular action due to many free liba- tions of fluids which at first more than gladdened his heart, was ordered to disrobe and be cleansed. He peremptorily refused and sought the house-physician saying: "Sir, 1 have come to you for protection. 1 have been grossly insulted by the orderly who insisted that 1 should take a bath. I take a bath! Sir, 1 am fifty years old, and have never taken a bath. No, sir, sooner than take a bath I will leave this place and never return!" The good-natured house-physician quickly perceiving the ludicrous side of 77 MORAL PHILOSOPHY OF MEDICINE the situation, said, using the high-flown style of the indig- nant plaintiff: " My good sir, since you have never enjoyed the luxurious, the delightful corporal sensation imparted by that elegant mode of ablution, do give it a fair trial, if only to satisfy my anxiety for your well being, and then do me the pleasure to apprise me of the outcome of your experiment." "Sir, your kind, considerate, and felicitous expressions suffice to induce me to acquiesce in the trial. 1 shall do so to gratify you since you have given your word that no violence is intended by that orderly whose tone and manner were so offensive." A few hours after- ward, the patient returned sobered up, shaven, shorn, clad in clean linen, saying: "Dear Doctor, thanks to your kind conciliating words, I undertook the experiment. It was truly delightful! 1 am now a clean man who shall ever be grateful to you. 1 want a bath every day. It is better for me than can possibly be any other medicine!" This case fully illustrates the excellent effects of a little tactful coaxing and of kind and gentle speech to the poor wretches who suffer so much brutal abuse in the highways and byways of great cities, and for whom the hospital is the only safe refuge. The efficiency of the house-staff of hospitals is promoted by the closest attention to duty and by the unceasing vigilance of the visiting-staff in true paternal spirit. As the members of the house-staff are the wards of the visit- ing-staff, so are the patients the wards of the house-staff whose guardianship is faithfully observed, and whose de- votion, tender care and special protection are daily be- 78 GRADUATE AS HOSPITAL-INTERNE stowed upon these wards. To dwell with the sick and suffering, striving to relieve their distress, is refining and softening to the feelings of the compassionate medical man, notwithstanding the oft-repeated statement of the un- thinking that physicians become hardened by long obser- vation of the pangs of sufferers! This is indeed a griev- ous libel on the character of the true physician who has been at great pains to learn to control his emotions lest their too strong manifestation unnecessarily alarm the patient or friends. 2. What should he avoided in the maintenance of disci- pline, and what demanded to assure the right management of the sick? It is the part of wisdom to dispense with long lists of rules and regulations placarded, as in former times, in the wards of hospitals, because they are likely to be, as they have been, disregarded, and thus be fatal to discipline; whilst a few simple explicit rules will surely be read and generally obeyed. Discussions, contentions, or even pleasantries, in the wards or anywhere before the sick, should be avoided as out of place and subversive of discipline. The sick being often irritable, impatient, querulous, and exacting, partly owing to long confinement to bed, partly to the nature of their ailments, or to the degree of their sufferings, the medical officers have long since found the best moral remedy in such cases to consist in forbearance, reassurance, kind words, due attention, and great patience in ministering to their mental and physical distress. It 79 MORAL PHILOSOPHY OF MEDICINE frequently happens, after a little mental tempest, that the repenting sufferer asks his dear Doctor to forgive him for having exhibited so much discontent, and warmly thanks him for so kindly overlooking the whims and caprices of a poor invalid. The conduct of a wise and kind physician in such circumstances, endears him to his patients and makes better men of them. As he treats his hospital pa- tients so will he treat his private patients. A crown-head, whose physician had reason to be anxious about the con- sort then in child-bed, said to him: "Doctor, treat her as if she were the wife of a tradesman, a spicer." Treat your patients of the hospital as if they were emperors and empresses because they are human; and treat your pri- vate patients as well and as kindly as if they were inmates of charity hospitals. 3. IVhat is the criterion of conduct of members of the house- staff in their relations to each other, to their visiting-physi- cians, to patients, and to attendants? The deportment of members of the house-staff should be that of accomplished gentlemen who never forget the courtesy due to all; who have in their souls a filial love and respect for their visiting physicians; who are faithful and considerate in their attention to the sick; and kind in their treatment of the attendants. 4. On his arrival at the hospital should the visiting-physi- cian await the coming of his house-physician before entering the wards? On the contrary it is the house-physician who should await the arrival of the visiting-physician and be ready 80 GRADUATE AS HOSPITAL-INTERNE with the rest of the staff to accompany him to the wards. This is a proper manifestation of the respect due to their foster-father on the part of the members of the staff who should never omit this ceremony which is a very whole- some disciplinary exercise. 5. In "making rounds," should the visiting-physician demand the attendance of every member of his staff? Assuredly. For he needs them all and, besides, it is much to their interest to be on hand and listen to his instructions by which to profit. 6. In standing around a patient's bed for his examination, how should the staff and attendant be placed? Ordinarily, the visiting-physician stands opposite the house-physician; next to the visiting-physician is the senior assistant with his book ready to note the remarks of the visiting-physician. At the foot of the bed stands the junior assistant, and beside the house-physician is the post of the chief attendant. 7. Does the visiting-physician address his remarks solely to the house-physician? The visiting-physician's general remarks on the patient's ailment and its treatment are for the benefit of all listen- ers, but in case of an unfavorable prognosis he reserves its statement for the ears of his staff exclusively. The patient should be spared the shock of such an announcement which may hasten his demise. It belongs to the clergy- man to break gently to him his sad plight while giving him spiritual consolation. Besides, the date of the fatal event cannot always be predicted with absolute certainty 81 MORAL PHILOSOPHY OF MEDICINE For this reason, the wise physician is generally cautious in his prognostications. Certain special remarks of a disciplinary character are addressed only to the house-physician and in privacy. 8. Does the visiting-physician question the patient directly, or through the house-physician? After the senior assistant shall have read the history of the patient and of his disease, the visiting-physician may choose to question the house-physician or the patient directly, or to obtain information from any one else likely to throw additional light upon the case toward assuring a correct diagnosis. 9. Does the visiting-physician ever rebuke publicly any member of his staff, or any attendant? No visiting-physician having a parental regard for his staff ever thinks of rebuking publicly any of its members or any attendant. When a rebuke is merited, it is made in privacy and in the form of a fatherly admonition or of a short instructive lecture. A well-trained staff scarcely ever needs any sort of rebuke. A public rebuke would always be subversive of the discipline of patients in any case, and would surely lead to loss of confidence in, and of respect for, the staff. 10. Does the visiting-physician allow patients to approach him privately with questions or complaints? No. Because this would be subversive of discipline. The questions or complaints should be addressed to the house-physician who, if necessary, may refer them to the visiting-physician who is likely to satisfy the anxious pa- 82 GRADUATE AS HOSPITAL-INTERNE tient by kind reassuring words, and the promise that his just grievances will meet with due attention. 11. What is the customary conduct of the visiting-physi- cian at the bedside, and in the operating room? The first clause of this question has already been answered in the replies to questions 6, 7, and 8. In the operating room, the rightly trained assistants know so well what each is deputed to do that the operator has but few orders to give and these are addressed to the house-physician. In the performance of an operation, howsoever intricate and difficult, there is no friction or confusion among well drilled assistants, or indeed in any case, so long as the operator is calm, composed, and skilful. Many are skilful, not so many are calm and composed in difficulties, and such are wont to lose self-control and thus create much disorder among assistants and attendants. A few remarkable instances of the freaks of neurotic oper- ators may be worthy of mention. The senior surgeon of a large hospital, a skilful, well meaning, but extremely excitable man during operations, was wont to clip off accidentally bits of flesh from the hands of his assistants and then scolding them for not "holding on and keeping still." In performing amputa- tions he generally flung away the knife quickly after mak- ing the flaps, much to the danger and annoyance of by- standers, then, severing the bones he would dash the saw to the ground instead of handing it to an assistant. His aids never knew what to expect, during the work of the master "except cut fingers" and were in constant dread of 83 MORAL PHILOSOPHY OF MEDICINE injury from the tools which he would throw about so care- lessly during his periods of excitement. Still they all liked him for his good qualities, and for his great kindness to them. Another operator noted for his amiability and gentleness in private life, was nevertheless the terror of his assistants at the operating table. Always finding fault with their doings and scolding all when there was no occasion. Many years ago, in a foreign city, was witnessed the worst instance of impatience and brutality on the part of an operator whose appearance and manners were more like those of a matador than of a physician. During a long and bloody operation, that executioner never ceased to grossly abuse every member and attendant of his staff; calling each by name, in the presence of a large audience. The half conscious, screaming, almost exsanguine patient was a truly pitiable object, and the arena of the amphitheater bore no little resemblance to a slaughter-house! Such sad examples are now fortunately of extreme rarity in this country or abroad. The house-physician has many sore trials, anxieties, and responsibilities. Called at all hours of the day or night, he often has but little time for study or for rest. He is too often censured for what he should be praised; blamed when he deserves the most credit from friends and rela- tives, sometimes of those very patients to whom he had given the most constant and intelligent attention. But conscious of rectitude, he is wise enough to be silent and await further developments; certain to clear him of all 84 GRADUATE AS HOSPITAL-INTERNE blame. So he goes on, in the even tenor of his way, per- forming his duties in good faith, until the expiration of his term of service when he receives due acknowledgment of his labors in the form of a diploma from the Medical Board and from the trustees or from lay governors of the institution, and at length becomes a candidate for the private practice of medicine. The moral lessons, the wise methods, and the good example of his teachers of the medical school and of the hospital will naturally lead him to enter upon his new professional duties with true scien- tific spirit for the weal of mankind. May he therefore ever bear in mind that virtue, knowledge, health, and activity are the primal sources of felicity of the student and physician; that moral rectitude, untiring industry, natural aptitude, and quick perceptions are the highest attributes of the genuine student and physician; and that the advancement of science, justice tempered with mercy and generosity, fidelity to duty, hope of lasting usefulness, and charity toward humanity are the noblest aspirations of the true physician. 85 VI THE YOUNG PRACTISING PHYSICIAN Requisites to professional success-The early years of medical practice-The acquirement of a clientage-The labors, anxie- ties, responsibilities of the physician in full practice-The growth of a physician's library-His equipment in medical implements-His iatrium-His obligations to the profession -When to begin writing for publication-Avoidance of con- troversy-The review of medical books-The question of specialism-The evil of self-sufficiency-The physician in politics. Beginners often ask-IV bat are the requisites to profes- sional and pecuniary success? These requisites may be summed up as follows: superior mental equipment, close observation of human nature, kindness, gentleness, prudence, patience, industry, energy, determination, tact, assiduous attention and devotion to sufferers, ability in diagnosis, skill in treatment, caution in prognostications, economy, the cultivation of good- fellowship in and out of medical circles, and a reasonable time given to social duties. Among his earliest acts, the young graduate should join the medical society of his county. He would thus come in close contact with his professional brethren and the attrition would surely be salutary. At the first meeting, he should be a silent listener, observer and learner. Later on, when becoming to him to take part in discussions, he 86 THE YOUNG PRACTISING PHYSICIAN would know then how desirable it is to be brief, clear, and pointed in speech and resist the temptation to wander from the main question, having witnessed how tedious, tiresome, and annoying the ubiquitous garrulous member becomes in his wordy ramblings; occupying so much of the time that would be better filled by others, and con- sequently being voted a bore; while the pleasing speaker expresses in the fewest well chosen words, the views which he desires to convey to his auditors. Whether the young graduate have or have not served as hospital-interne, his clients will acknowledge his services strictly in accordance with their character and success. His devotion to the further study of the healing art, his developing skill, his powers of observation, his contribu- tions of lore to medical societies, and his moral principles, will determine his standing in and out of the profession. His worldly intercourse will exert upon him the greatest influence throughout his career. Therefore he cannot be too solicitous of the habits of his acquaintances or too cautious in forming intimacies, for he will be judged by the character of his close associates. The good people with whom he has official relations, those whose frequen- tation he cultivates, his early friends, will all be helpful to him in the near and distant future, provided his conduct toward them has been always fair, just, generous, and honorable. His chief guiding principles should be equity and reciprocity, and he should keep in mind these few ancient adages and always act in accord with their teaching: 87 MORAL PHILOSOPHY OF MEDICINE "In behavior be thou always civil, polite, kind; without show of condescension or patronage." "Let thy manner be dignified, without pride." "Have no intimate friends not equal to thyself." "Cultivate the friendship of the learned and virtuous." "Love all, trust a few, do wrong to none." " Be able for thine enemy rather in power than use." " Keep thy friend under thy own life's key." "Be check'd for silence, but never tax'd for speech." "Only in the faithful service of God, country, mankind, letters, science and art, wilt thou find true happiness." He should treasure in his mind, also, that justice inspires respect, mercy begets honor, generosity engenders good will, kindness enkindles friendliness, sincerity assures trust, charity breeds gratitude, and industry prompts reward. He should avoid being drawn into the trap so often set, to catch the innocent and confiding garrulous neophyte, by certain gossiping flatterers who will encourage him to speak much of himself and of his deeds, only to repeat and exaggerate such speech to his detriment. He should al- ways be on his guard with those mischief-makers who also by flattery endeavor to lead him to severe criticism of men to whom his words and many additions of their own are to be detailed; and remember that conversations about things are always harmless and less tedious than reflections on persons. At no time or place should he speak of a col- league or lay acquaintance unless he have occasion to do so in praise. Censorship is generally a fruitless and 88 THE YOUNG PRACTISING PHYSICIAN thankless office. He should not "talk shop" in polite society or even to professional associates out of the sick room or of private medical conference. He should not, on any occasion, speak lightly of a colleague's treatment of patients, particularly in cases of broken bones. A word or a look of disapproval in such instances has proved extremely injurious to the physician in charge and has led to burdensome litigation with much loss of time and repu- tation besides, too often, the imposition of heavy damages on the innocent, for, as is so well known, non-union or ill- union of fractured bones is the fault of the patient in the vast majorities of cases. As a general rule, during the first few years of his prac- tice, the beginner has an abundance of spare time for study and for the care of poor patients in some dispensary, and thus be in a position to gain the experience needed for his future guidance in private practice, and at length fit him to take the desirable and honorable position of visiting-physician to a hospital. He should give himself no concern as to when or whence might come his first remunerative client so likely to appear when and whence least expected. With laudable pride he would then in- scribe that client's number, name, and date of first visit in bold letters in the neatest of note books at the head of a full and carefully written history of the case, and there also record the amount of the fee, and the expressions of gratitude for the service rendered. In the successful man- agement of the case, the devotion, gentleness, and skill of the resourceful young physician doubtless won for him the 89 MORAL PHILOSOPHY OF MEDICINE esteem and approval of the patient and friends, and placed him in a fair position to thrive, for all probably sounded his praises and soon sent him new clients who in turn recommended to others the energetic and well-versed physician whose clientage increased from year to year until his services were eagerly sought by the many, and his emoluments had placed him in a situation permitting him to devote more time to the advancement of the art. Such is the way in which many eminent physicians have built up their practice, have gained their fame, and have continued to be useful in advancing years. The other side of the physician's life does not now inter- est the young optimist, but later he will realise that the path of the busy physician is not always smooth. He will then learn, of the extent of his harassing labors, of his anxieties, of his great responsibilities, and of the little time at his disposal for study, for recreation, and for domestic relations. He will witness or perhaps feel the occasional depression of spirits caused by the conduct of the faithless and ungrateful upon whom he had bestowed so much attention, time, and devotion and who had made no kind of recognition for those services but on the contrary had heaped abuse upon him. He will also witness the irrita- tion and vexation of the honest and capable physician arising from the covert and even public belittling of his deeds, for their own selfish ends, by those shrewd medical freebooters whose black flag so soon comes to view, but whom, however, he should rather pity, forgive, and for- get, than brood over their intended injury certain to react 90 THE YOUNG PRACTISING PHYSICIAN upon them if he persevere in a dignified silence, and exer- cise justice, mercy, generosity, and charity toward all; thus maintaining his high professional standing and being assured of the unflinching support and constant affection of his clients and the respect of the community. Launched in public and private practice to compete with those already in the field, the well-equipped beginner is ready to meet the demands of modern science. His men- tal tools, consisting of a few judiciously selected books and journals, will be in very much greater use, at first, than his oxydisable metal implements. His library, hav- ing for nucleus the little literary collection made during college days, and the medical text books, should, like the rocks, grow by very slow accretion through the gradual acquirement of such new books as he may actually need and has time to read. He is of course provided with a Roget's Thesaurus and with the Greek, Latin, English, and medical lexicons so indispensable to the faithful laborer in the science and art of medicine. Other works of refer- ence are always accessible in the public libraries. His equipment in medical implements should be simple and only sufficient for present purposes. Some reagents, a microscope, a stethoscope, a pocket case of needful instruments, a few catheters, and such other instruments as are absolutely necessary in cases of emergency, together with a proper assortment of medicinal substances in con- centrated form, should constitute his armamentarium. Other things to be added as required from time to time, for he should not be burdened with a profusion of costly 91 MORAL PHILOSOPHY OF MEDICINE objects so many of which he may scarcely ever have occa- sion to use. All his surgical tools should be under lock and key and never displayed to the gaze of visitors as their sight, besides being somewhat gruesome to the laity, can be conducive to no good whatever. The so-called office is really the study of the physician where he lives, as it were, with his books which are the only tools in sight for constant use; this study being his iatrium furnished in good but simple style with nothing to show that it is anything more than the dwelling place of a man of taste and culture. Faithful in the performance of his duties to patients, the true physician will treasure in his mind the wise Bacon- ian maxim that every man is "a debtor to his profession; from which as men of course do seek to receive counte- nance and profit, so ought they of duty to endeavor them- selves, by way of amends, to be a help and ornament thereunto," and therefore will not be forgetful of his obli- gations to the profession; comprising regular attendance at meetings of medical societies, contributions of lore for the common good, the report of cases of disease, the pre- sentation of short essays, loyalty to his colleagues, instruc- tion of the young, etc., etc. In reply to the question-When should a physician begin to write for publication? He would be told that he need not follow Horace's advice to the letter, but to keep it in mind, and to study Boileau's "Poetical Art" and Pope's "Essayon Criticism"; and,moreover, that although trained in medical writing from the time he began to take notes 92 THE YOUNG PRACTISING PHYSICIAN of lectures, the thoughtful young physician would scarcely believe that even such expertness could give him sufficient material for the composition of a serious essay. So he would be advised to wait for experience in public and private practice before making his first literary venture, and not think of writing for publication, even by way of report of a single case, until satisfied that he has some- thing to say that may be of scientific value; and should not print until after three revisions, at least, of the matter and manner of his essay. Such precaution would save him not only from the cruel stabs to his feelings by those inexorable critics that give never a vestige of encourage- ment to struggling beginners, but, in after years, from regret that he ever issued so many crudities as are produced by the hasty. Let his trial piece be in the form of an analysis of his first few scores of cases of a kind extracted from his note book, and let him add and analyse similarly as many illustrative cases as he may find recorded in books and journals. To his second essay, which must make him if he give it proper care and attention, or other- wise mar him, he should give it at least twelve months' time and strive to reduce it to twenty or twenty-four octavo pages, for in either space any ordinary question in medicine can be presented and fairly discussed in a clear attractive style. He will then have realised the difficulty of giving proper and short titles to essays, and soon learn to avoid those very long titles that some modern writers use in imitation of certain old authors who were wont to crowd the title pages of their treatises with matter which 93 MORAL PHILOSOPHY OF MEDICINE belong legitimately to the preface or to the introduction, and which so marred their works. Five or six appropriate words, and less whenever possible, ordinarily suffice for the title of any essay or chapter, and at least show good typographic taste. Many excellent papers are cast aside unread solely on account of their inordinately long or pre- tentious titles. Above all he should avoid using such titles as "An interesting case, an unusual case, a unique case," or any of the many other vague designations so commonly employed. The young writer should not be discouraged if his essay, in the preparation of which he has taken such pains, should be fiercely assailed by domestic or by foreign critics for, few authors have been exempt from unjust criticism by the super-censorious who often have drawn them into the most vexatious contentions. Let him beware of med- ical controversy; but if ever forced into such a debate, let him keep his temper, fortify himself with the all-power- ful aegis of truth, state his case briefly in simple, pure, clear, exact, language expressed in few but well fitting words. Let him be precise and accurate in quoting from the text of his adversary's attack; let him be just and generous toward that opponent; and, above all, let there never be the faintest trace of gall in the ink of his defense. When, in turn, the young physician receives medical works for review, though he assume an unenviable and thankless task, he nevertheless derives useful information in their perusal and should make, in his criticism, a suit- able acknowledgment of their merits instead of looking 94 THE YOUNG PRACTISING PHYSICIAN solely for their faults, as too many do to whom criticism has the one signification of condemnation and never any- thing like laudation. It does not seem to captious critics that the examination of a work may result in the praise of its good qualities as much as a fair statement of its defects. It is only the vainglorious carping criticaster, with the most superficial knowledge of the subject of his attempted criticism, who spends his time fruitlessly in writing what the author had not said or should have said, whom he failed to quote, and why he did not mention A and B. whose works in reality had no pertinence whatever to the subject of the review; or he goes to the opposite extreme and praises another work which happens to be worthless. The competent young reviewer takes into account human fallibility and is not too ready to accept a mere opinion, even when given by one high in authority, unless it be based on a rational interpretation of well authenti- cated facts which alone are of scientific value. Every student of literature and science knows how difficult it is to form a correct judgment of the merits of written or printed productions even after repeated examinations, and that fair, unbiased, just criticism is never easy even to the experienced reviewer when he makes the best use of that refined discernment which is able to seize the beauties of a poem or of lofty prose, and to distinguish the perfect from the mediocre, the noble from the sublime, and find for each its rightful place. The fairest reviewer then is he who knows thoroughly well the subject of his review, 95 MORAL PHILOSOPHY OF MEDICINE and who is blessed with clear perceptions, good sense, superior literary taste and sound judgment. A young medical man asked "at what time in the career of a physician may he begin the special study of diseases of particular organs or regions of the body?" This question, so often asked, has been answered in the same spirit and substantially in the same letter as the following: The physician, after five years of general practice of medicine when he will have had ample opportunity to observe the divers phases of many diseases, and to acquire due skill in their diagnosis and treatment, may, if his inclination be toward specialism, begin the closer study of disease of some particular organ, apparatus, or region of the body. During this second period of five years, while still engaged in the special study, he should continue his general practice which would have the good effect of hin- dering the too sudden decrease of his field of observation, and also serve to fit him all the better to confine his labors to the restricted new field without danger of mental coarc- tation. At the end of the second five years, that is to say, ten years after graduation, he may safely exclude all patients affected with diseases other than those to which he is giving special attention. So that, according to the views of Doctor Storer, the successful specialist must first have been an especialist who is a physician in general prac- tice that gives especial attention to the diseases of some particular organ, apparatus, or region of the body. This, of course, would be during the second five years, or later, of practice when he could continue for an indefinite time 96 THE YOUNG PRACTISING PHYSICIAN as an especialist, or devote all his energies to the study and treatment of the diseases of a particular organ, appa- ratus, or region of the body and thus be a pure specialist; his clients, at first, coming from colleagues who are gen- eral physicians, and later, as his reputation for skill is extended, also from sufferers who have been under his care. On this subject of specialism, sentiments worthy of serious consideration are contained in Doctor Flint's ad- dress on "Medicine of the Future," and are now quoted for the benefit of young specialists: "The unavoidable subdivision of medical literature and medical instruction into special departments makes neces- sary, to a certain extent, specialism in the practise of medicine. It is certain that this will not lessen, but increase, in the near future; and it is important to think of possible emergencies which are even now foreshadowed. Specialism conduces to the advancement of knowledge. It behooves us, however, to consider, were the practice of medicine to be given up to specialists, what would become of the medical profession. With due appreciation of services devoted to special branches of medical knowledge, there are tendencies pertaining to the practice of a specialty that should not be overlooked .... the danger of what may be called professional demoralization . . . . A dangerous tendency is to such a limitation to a specialty as will lead to withdrawal from the common interests of the profession. A medical specialist should not thereby, in his sentiments and conduct, be any the less a physician; 97 MORAL PHILOSOPHY OF MEDICINE the honor, dignity, and usefulness of the profession, as a whole, should be as sacred in his estimation as if he were not a specialist. If the effect of specialism be otherwise, alas for the medical profession of the future, as regards the respect of others and the self-respect of its members!" I'he same young physician propounded the following question: "What are the best ways for a busy physician to prevent his becoming narrow, conceited, and arrogant?" There is no hope whatever of bettering the mental and moral status of the narrow, conceited, arrogant, ignorant boor who styles himself a physician and assumes superior- ity over all others, for he is a true type of the congenital charlatan who would not if he could alter his ways. But the honest busy physician, too much occupied to emerge from his mental shell, is likely, at length, to realise that self-sufficiency is hardly becoming and that he must make a radical change in his habits and begin to give more atten- tion to the doings of others and thus to profit by that wholesome attrition which will soon smooth his mental asperities and which he will find in the medical societies where he will be continually learning some good and use- ful things, where he will discover that there are many who know quite as much as he does, and others that are his betters in medical lore. He will then fully appreciate how becoming is true humility in science, and how neces- sary it is to the increase of knowledge. With the help of a brother physician he will soon be rid of his sour mental and physical dyspepsia, become really cheerful, go among his friends to show that he has foresworn solitude, take to 98 THE YOUNG PRACTISING PHYSICIAN smoking good cigars, to reading entertaining works of fic- tion, and even to reading medical journals like any other plain unpretending physician, lest he degenerate, as he had been warned, into a veritable modern Doctor Akakia- self-satisfied, safe, stupid, harmless; forgetting nothing learned at college, but obstinately refusing to adopt new methods. The propounder of the question doubtless had encoun- tered some unfortunate, untutored medicaster afflicted with the peculiarities which he so aptly characterized, and therefore thought that a remedy or, at least, preventive measures might be suggested for the benefit of those threatened with the infirmity. But the affection is gen- erally congenital and gives little or no promise of cure. However, in some sporadic cases of great acuity, the malady may be nipped in its budding stage or, at least, relieved, by the means already indicated. It is not un- likely also that the inquirer was led to ask the question after reading the account, by Athenaeus, of the Syracusan Menecrates who had given himself airs as being, by his skill in medicine, the only person who could cause men to live, and compelled all who came to be treated by him of epilepsy, then called the sacred disease, to enter into an agreement that if they recovered they would be his slaves. And so they followed him wherever he went,all attired in the style of divers gods and demigods, whilst he person- ated Jupiter, shod with slippers, clad in purple, having a golden crown upon his head, holding a scepter, and thus going about with his chorus of gods. He once wrote to 99 MORAL PHILOSOPHY OF MEDICINE Philip as follows: "Menecrates Jupiter to Philip greeting. You, indeed, are. King of Macedonia, but / am the King of Medicine, you put men to death who are in health; but I save the sick The Macedonians attend you as body-guards, but all who wish to live attend me, for I Jupiter give them life." And so Philip wrote back to him as to a man out of his senses-"Philip wishes Mene- crates soundness." The charlatans of the present time take entirely differ- ent and much more subtile means to deceive the credulous public. It may be interesting to the beginner to look into the early and the present significance of the words empiric, quack, and charlatan designating the ubiquitous pretender who has always been the worst of the young physicians' opponents. Pretenders in medicine were spoken of by Hippocrates in the first section of his "Law," as follows: "Such persons are like the figures introduced in trage- dies, for they have the shape, and dress, and personal appearance of actors, but are not actors, so also physi- cians are many in title but very few in reality. The word agyrtes was used by the Greeks to signify a person of bad character, a vagabond, an imposter, or a juggler who was also styled thaytopoios, conjuror; all of which are significant of empiric, quack, and charlatan. Empiric, from em, in, and peira, trial, attempt, was the designation of a sect of irregular physicians who founded their practice on experience without theory or adequate 100 THE YOUNG PRACTISING PHYSICIAN knowledge, and were opposed to the sect of methodists and even to the dogmatists. Their champion, Serapion of Alexandria, was characterized by Galen as an arrogant, self-sufficient, empty, and overbearing pretender. Quack, literally meaning one who, in speaking, quacks like a duck, has long been in use among English writers as an abbreviation of quacksalver to signify the mounte- bank who, in pattering jargon, was wont to vaunt the efficacy of his salves, unguents, and other wares. Charlatan, defined in the lexicons as a pretender, de- ceiver, cheat, fraudulent chatterer, mountebank, tattler, prater, empiric, quack, was introduced into England from Italy during the sixteenth century, and anglified from ciar- latano, from ciarlare, to prattle. Medical pretenders are ever striving to belittle legiti- mate medicine and, by flattery and other insinuating means, to secure the good graces of their chief prey the great and wealthy. One of the earliest examples is that of Thessalus the Lydian who practised upon the credulity and the strong boxes of the Romans during the reign of Nero. That blatant charlatan, among his other preten- tions, professed to teach the art of medicine in six months, and actually had a large following of crafty pupils from the lowest ranks of society. It is needless to say how much his evil practises are followed in these modern times! The first principle of the charlatan has always been to gather wealth mainly through deceit and imposture. He appears everywhere in different forms and under different names. His prattle is hearkened by the unthinking ma- 101 MORAL PHILOSOPHY OF MEDICINE jorities and he thrives, for a time at least, but often comes to grief. His decrial of the regular profession is unceasing, and he is ever ready to place himself in a position to raise the cry of professional jealousy and persecution. There- fore it behooves all physicians, particularly in small towns, to ignore his existence and never allow themselves to be led to speak of his acts or his mode of practice, but to spend a reasonable amount of time toward the education of his clients and of the public as to the nature and aims of legitimate medicine and the reciprocal obligations of patient, community and physician. The question was asked-"should the physician take part in politics?'' Unquestionably. He should never forego his privileges of citizenship, and is in duty bound to mix in politics for the chief purpose of advancing the interests of the pro- fession in many particulars, but especially for the promo- tion of State Medicine. For the attainment of these noble objects it is surely the bounden duty of all physicians to take a sufficiently active part in local and general politics; then the public and the state will have the fullest realisa- tion of the power of a united profession, and every phy- sician will also realise that, high as is his achievement of curing disease and of alleviating human suffering, he should aspire to the still higher object of preserving the health of the people; to accomplish which he will have to make demands which the state must grant. But this question will be better and more completely answered in the following language, extracted from an 102 THE YOUNG PRACTISING PHYSICIAN admirable article on "The Physician as a Citizen, con- tained in Stephen Smith's "Doctor in Medicine." "It is not a little singular that in a government where the duties as well as principles of the citizen are indefi- nitely extended, where, practically as well as theoretically, he is the sovereign, there should be a class of persons who lightly esteem their civil obligations. And it is still more remarkable, nay, marvelous, that such a class should be found in a profession which holds the most intimate rela- tions to those influences through which the most bene- ficial results to society may be secured. In European countries medical men regard it as a proud distinction to be in the service of the state The most prominent physicians labor for years to attain courtly rank or positions in government service American medicine will have but half fulfilled its mission when it attains the rank it seeks only as a science. Upon it are also laid the burden and responsibility of important social reforms which it alone can accomplish. Preventive medicine or the practical application of sanitary science to the art of living, is yet to engage the earnest attention of medical men in this country. But whoever enlists in this great work must, for a time, incur the odium that many foolishly and most unjustly attach to those public movements of medical men necessary to the establishment of proper organizations. But let them not be disheart- ened. Preventive medicine will yet be recognized . . . . as the noblest branch of the science, and those who succeed in systematizing its operations among our 103 MORAL PHILOSOPHY OF MEDICINE people will be regarded as the most worthy of the profes- sion, as well as public benefactors." To the question-"Is there much advantage in the visita- tion of European medical centers?'' The answer has gen- erally been fliat, to the recently graduated, such visitation particularly if it be short, is not advantageous for, his youth and insufficient experience are not equal to the formation of a sound judgment of the performances which he witnesses. The proper time for foreign peregrinations is after at least five years of private practice when the physician is better fitted to contrast transatlantic and domestic methods and to profit by their study. No young physician should think of going abroad until he knows something, by actual observation, of the great lights of the profession and of the medical institutions in his own country. The young physician who is imbued with the great moral principles established by the patriarchsof medicine, and who follows the good and noble example set by them, will never forget that medical commercialism, cupidity, and self-aggrandisement are not the characteristics of the true physician who is in honor bound to guard the dignity and high character of the profession of medicine, to help in maintaining the highest standard of qualification for the practice of the art, and to contribute his full share of lore toward the extension of the boundaries of this already vast field of science. 104 VII SENSE CULTURE. VISION AND ADDITION The early cultivation of the senses essential to the proper con- duct of the study and practice of medicine-General remarks on the five senses-The visual sense-Seeing with the mind's eye-Quickness of visual perception; its importance to the physician; how to exercise it-The auditive sense-Exercise of the mind's ear for correct interpretation of heart and respiratory sounds, etc.-Music as an aid to the cultivation of audition. The importance of early beginning the cultivation of the senses, in order to bring them up to a high degree of efficiency for guidance in his present labors, is soon realised by the diligent student who, later, profits so much by this culture in his medical practice and social relations. How to cultivate the five senses, for his present and future purposes, with the least labor and the most pleasure, is now to be told as briefly as the subject may allow. How- ever, a few preliminary remarks on the senses in general are needful toward the elucidation of such questions as are likely to arise in the mind of the listener. Each wonderfully designed human sense apparatus necessarily has, in each individual, its own peculiarities of construction and action, as, otherwise, all mankind would see, hear, feel, smell, and taste with an equal degree of precision. But if such were the case, there probably 105 MORAL PHILOSOPHY OF MEDICINE would be little interchange of ideas or spicy expression of like or dislike for particular objects, and possibly as little observation of the phenomena of nature which so teems with variations in the animal and vegetable kingdoms. Although it is mainly upon the animal man that attention is now more particularly fixed, a glance, for comparison, may be cast profitably at the most glaring sense peculiari- ties of some of the lower creatures. Of visual peculiarities, it has been asserted that certain nocturnal animals, such as bats and owls, are not able to distinguish colors because of the absence, in their retinae, of those minute conical bodies that are believed to be essential to the perception of tints, whilst the eyes of some diurnal birds, that hunt bright colored insects, are very richly supplied with retinal cones. Extremes like these need not be regarded as imperfections, for they are really variations needful to the habits of those creatures. It has also been suggested by some observers, and denied by others, that congenital "color blindness'' in man is due to a greatly disproportionate number of retinal rods and a paucity of cones. The subject is well worthy of further investigation. The specialisation of color tints is ex- tremely delicate among the fair sex, particularly in adoles- cence; and great advantage has been taken of this knowl- edge in the arts. In the visual sense of man, the varia- tions, known to exist entirely in the refractive apparatus of the eye and to interfere with the right appreciation of certain objects seen, are many but nearly all remediable. The auditive sense of many of the higher vertebrata is 106 SENSE CULTURE well known to be much more acute and alert than that of man, though in construction their middle and internal ears bear some resemblance to those of man, particularly the beasts that are much preyed upon and must be quickly aware of the approach of an enemy in good time to flee. It is said that aquatic animals have no middle ear, which would be useless to them because, in their case, sound waves are easily transmitted from the ambient to the labyrinthic liquid. The sounds inaudible to the unaided human ear are the extremely shrill and the extremely grave. The physicist's whistle is thus unheard. The hum of a swarm of gnats is scarcely audible, and the bellowing of the whale is so grave that it has no effect whatever on the ear-drum of man. That leviathan has been seen, not heard, calling to his mate. In the first or second case the drum-membrane cannot be made to vibrate naturally with sufficient rapidity, that is, more than thirty-five thousand times per second, and in the third case the drum-head is not adapted to the very slow vibrations, less than two per second, requisite to render audible these gravest of sounds. The tactile sense is possessed in a higher or lower degree by superior as well as inferior organisms. In these, how- ever, it will require long and persistent researches to deter- mine its diffusion; though it is already known to exist in some plants, notably the carnivorous whose peculiar leaves so quickly enfold lured insects and remain tonicly closed until the bodies are consumed. The many tentacles of the sea-anemone serve to feel, select, and convey its prey 107 MORAL PHILOSOPHY OF MEDICINE to the ample oral aperture. The taction of the oyster or clam is sufficient to cause the creature to close its shell on the near approach of an unwelcome intruder. The long antennze of crustaceans serve well the purposes of touch, and even give warning of approaching prey or danger. This sense is well developed in many insects whose antennae are as long fingers. In birds, the sense of touch is exquis- itely delicate, particularly in the beak near the tip of which have been found well-organized tactile corpuscles. In mammals its variations are without end, up to man. The wings of the common bat are said to be so richly endowed with tactility as to enable the animal to "sense objects without actual contact." The larger beasts touch mainly with the end of the nose, the lips, and the tip of the tongue; the sense is comparatively blunt in other parts. The stiff antennae-like hairs near the angles of the mouth, notably of the felidae, are delicate tactile organs at the base of each of which is a touch corpuscle. The end of the elephant's proboscis is possessed with such tactile delicacy that with it, the huge monster is able to pick up a single straw. The olj active sense of some of the vertebrates is much keener than that of man, though not so delicate; but that sense, in certain tiny creatures, is very highly developed, as in those insects that have to see extremely small objects with their thousand facetted eyes and their ocelli, while they "find their food more by smell than sight," such as the ants who have only fair vision, but very strong olfaction. 108 SENSE CULTURE The gustative sense of beasts has been illustrated from very low forms up to domestic animals where it is strong- est even to daintiness, as in the case of cats and dogs. In men, gustation is susceptible of great cultivation, but the greatest height of gustative delicacy is to be sought only in the better half of man. In each order, genus, and species, including man, the senses are developed and varied in proportion to the needs of the creatures. These sensual variations, which are in no sense defects, are almost infinite. It has long been observed that when one sense is im- paired or destroyed, other senses acquire increased activ- ity by way of compensation. For instance, in the case of the blind, the olfactive and auditive senses are much more alert than formerly, and tactile sensibility becomes very delicate even in the soles of the feet. A physician, who had lost his sight soon after entering upon the practice of his profession, determined to devote himself to teach- ing and became an accomplished quiz-master with a large following of pupils who took turns as his readers. He had a phenomenal memory, and such a great power of concen- tration of attention that after listening to the reading of a whole chapter he could repeat it word for word. He had so cultivated his auditive and tactile senses that sounds almost inaudible to others were distinctly heard by him and, bat-like, the slightest waves of air announced to him the approach of persons whom he was generally able to call by name, but it was mostly through the tone of voice that he distinguished individuals. He daily went 109 MORAL PHILOSOPHY OF MEDICINE about the streets often to distant places unaccompa- nied except by his gold-headed stick and seldom missed his way. It is said that, during the dense fogs which so often prevail in Holland, blind men have served, in the streets, as guides to strangers. The deaf's sight is ever attentive to the slightest move- ments of other persons, and the deaf and dumb are wont to cultivate highly the tactile and visual senses. No examples need be given; they are so many and so well known. The most remarkable example recorded of compensa- tive sensual action is afforded in the case of Laura Bridge- man who, at the age of three years, had contracted scarla- tina which resulted in the total loss of the power of speech, of sight, and of hearing; taste and smell being almost abolished; leaving only the tactile sense unimpaired. At eight years of age, sound in mind, she was sent to the South Boston Asylum for the Blind, where her education was conducted by the devoted Doctor S. G. Howe, the inventor of a raised alphabet for the blind. She made very steady and satisfactory progress in her studies, en- joyed several accomplishments acquired entirely through her exquisitely developed tactile sense, and lived happily to the age of fifty years and some months. It is not easy to decide which of the two is the more interesting figure; the marvelous pupil or the gifted and truly wonderful master. Laura Dewey Bridgeman survived her dear teacher Doctor Samuel Gridley Howe by thirteen years. 110 SENSE CULTURE She died on May 24, 1889, and the Doctor on Jan. 9, 1876. Some very extraordinary cases of deaf-blind children have lately attracted much attention and have greatly encouraged educators in promoting the cultivation of the tactile sense of the blind. The most wonderful of these cases is Helen Keller whose marvelous ability is so well known. Among the other interesting examples are: the bright boy Tommy Stringer; another phenomenal boy Leslie Oren; Linnie Haguewood; Cora Crocker; Marion Roston; and others whose touch has been cultivated to the most exquisite degree of sensibility as the sole means of education. In all these cases the most satisfactory results have been the high reward of the diligent pupils and the devoted teachers. These several cases fully monstrate how much can be accomplished by an intelligent person even when all but one of the five senses are destroyed, and serve to enforce the belief that mental impressions can be received only through a sense apparatus, there being no other avenues; that man's idea of the Creator is derived solely through his sensual cognizance of design in creation; that his con- sciousness of a creator is attained wholly through the creation, to perceive which he must see, hear, touch, smell, or taste; and that design necessarily implies a designer. It is clear then that sense culture does not mean the simple exercise only of the end organs which, of course, are stimulated to more efficient action by the right kind of training, but signifies exercise of the whole of each 111 MORAL PHILOSOPHY OF MEDICINE sense apparatus to its terminal cerebral center. There can be no real conscious vision, audition, taction, olfac- tion, or gustation until the impression made upon the end organ is conveyed to the perceptive center. The Father of Medicine evidently wished to emphasize the importance of sense culture when he said: "It is the business of the physician to know .... things .... which are to be perceived in the sight, and the touch, and the hearing, and the nose, and the tongue, and the under- standing." For the easy and pleasurable cultivation of his senses, the student can adopt no better method than that of Zadig, taught so well by the Coan sage. The visual sense, which he must use so much in his observations, will naturally be the first to attract the stu- dent's attention, and this may possibly cause him to resort to artificial means to ensure distinct sight, such as the use of glasses suited to the peculiarity of the refractive apparatus of his own eyes. And he will surely invoke the aid of magnifiers for minute dissections, and of the com- pound achromatic microscope for bringing to light myriads of objects invisible to the naked eye. He is not long in learning that human vision is dual, that men too often look without perceiving, and that it is mainly this per- ceptive faculty that will respond to early cultivation. The end organ may be sluggish, but its constant exercise will incite wonted activity provided the retinal rods and cones and the purple pigment be normal and the refrac- tive apparatus in proper condition. He knows that vision can be complete and satisfactory only when it reaches its 112 SENSE CULTURE perceptive center in the brain, and that, therefore, to perceive anything visible the looker must see with his mind's eye, and thus be able to judge quickly of the inten- sity of its light, the quality of its color, the nature of its form, and, approximately, the extent of its dimensions. No better illustration of seeing with the mind's eye could be given than the following: The sense of sight, said Sydney Smith, "is indeed the highest bodily privilege, the purest physical pleasure, which man has derived from his Creator. To see that wandering fire, after he has finished his journey through the nations, coming back to his eastern heavens, the mountains painted with light, the floating splendor of the sea, the earth waking from deep slumber, the day flowing down the sides of the hills till it reaches the secret valleys, the little insect recalled to life, the bird trying her wings, man going forth to his labor-each created being moving, thinking, acting, according to the compass of its nature, by force, by cunning, by reason, by necessity .... turn .... to the plentiful valleys; to the fields now bringing forth their increase; to the freshness of the flowers of the earth; to the endless variety of colors; to the grace, the symmetry, the shape of all it cherishes and all it bears " Quickness of visual perception is well illustrated by cer- tain incidents related in the life of the celebrated Robert Houdin who, for visual exercise, was in the habit of glancing at shop windows, accompanied by his young son and, immediately after passing by, asking the boy to 113 MORAL PHILOSOPHY OF MEDICINE name their contents. When the child omitted to mention a few of the articles, he made him look again and again, in passing rapidly, until every object was named. Before long the son was almost as skilful as the sire and generally a single look was sufficient for him to descry and name a score of different objects. Once, the father, without stopping, walked through a private library, which he had never seen before, and entered an adjoining room, when he immediately gave the title imprinted on the back of each book, of a long row, on subjects in which he had no particular interest or knowledge. These excellent examples of quickness of visual percep- tion, acquired by persistent practice, are well worth fol- lowing by the student who, while out for recreation, or during the summer vacation, can go through a similar training with little labor and always with much pleasure, if he form the habit of frequently interrogating nature whether in town or country, but especially during his rambles in the fields and woods where he should allow nothing to escape his scrutiny, and see with his mind's eye so many things invisible to the unobserving glance. His mind will then expand as much by comparing the smallest and largest objects of a kind as by contrasting circumscrip- tion and vastness; his close observation of the so-called great and small showing him the Creator's infinite wisdom in designing these and all other things, from the largest sun to the minutest particle of cosmic dust, nay, even to the molecules, ions, and atoms, with a view to their uses and to their fitness for the places they occupy, and con- 114 SENSE CULTURE firming him in the belief that little bodies are as thoroughly well adapted to their surroundings as are the big; so he reaches the inevitable conclusion that, in nature, there is neither great nor small; all things being relative. The early exercise of visual perception is of incalculable value to the diagnostician and prognostician in the inter- pretation of facial expression in disease, the study of which began with Hippocrates who so concisely described the expression of the moribund that facies Hippocratica is given to the appearance of a sufferer with an unnaturally "sharp nose, with eyes hollow, temples collapsed, ears cold and contracted, forehead rough, parched and distended, and face livid, dark, or lead-colored." The distended nostrils and labored respiration of a patient, the staring eye of another, the depression of the angles of the mouth of a third, and the expression of great suffering or of terror in a fourth, so well depicted by Charles Bell; each has its significance to the shrewd and quick observer the moment he enters the sick-room ready with his min- istrations for immediate relief, and then free to question the sufferer or attendants, complete the diagnosis, and prescribe further treatment. Culture of the visual sense may be made subservient to the worldly relations of the physician who should be an accomplished man of taste in arts, as well as learned in letters and science. Therefore, occasional visitations to collections of living animals, parks, museums, and art galleries, and the frequentation of clever artists, should become a part of the student's recreation. There he can 115 MORAL PHILOSOPHY OF MEDICINE cultivate his feeling for color, form, landscape, statuary, and thus learn to be able to judge of the beautiful, the sublime, the picturesque, and the statuesque. The auditive sense has ever been on the alert, for, the first sound hearkened by man was that of his own voice when, after the first breath of air, he cried lustily and, ever since, has been very fond of hearing himself talk. The child listens with joy to his own prattle and to his shouts which the fond matron so surely distinguishes from the cry of pain or the scream of alarm that recognizing the last, with the keen ear of motherly love, she flies to the rescue. The sound of the human voice differs so greatly from that of beasts that these, whose auditive sense is of the acutest, hearing it from a distant point, are soon ready to flee from their formidable enemy man who himself, at first, was affrighted by the whistling wind, the growl of distant thunder, the roar of the lion, or the bray of the ass. In time, however, courage came with knowledge. Then began his discrimination of noises to which he listened with the mind's ear and thus perceived that cer- tain distinctive sounds were made by different animated creatures which he strove to see; as the croak of the frog, the hiss of the serpent, the chirp of the cricket, the buzz of the bee, the pipe of birdlings, the hoot of the owl, the cluck of the hen, the crow of the cock, the cackle of the goose, the bark of the dog, the yaup of the fox, the howl of the wolf, the grunt of the swine, the bleat of the lamb, the bellow of the bull, the neigh of the horse; and soon 116 SENSE CULTURE the moan of the parturient, the pule of the new-born, then the merry laugh of the child, the shouts of the boy, and the yell of the multitude. All these and myriads of other sounds are quickly specialised by the practised human apparatus of audition which is the most complicated of the five, consisting, as it does, of a sort of resounding board known as the pavilion of the external ear, serving also to indicate the direction of sounds which it sends inward, through an ample conduit to the drum-membrane separating the middle and external ears; of the middle ear, partly walled by hard bone, receiving air by means of a tube from the back part of the nasal cavity; and the internal ear, separated from the middle and embedded in bone of stony hardness, with its labyrinth in which are those marvelous organs that serve to specialise so well the most delicate modulations of sounds. • To exercise the auditive sense with advantage, the stu- dent should hearken to every sound with the ear of his mind, without which there can be no real audition; he must heed to hear, he must hear well to interpret correctly. When, directed by a master, he listens to the heart-beats, he soon learns what their nature is in health and then in disease, and by his perception of their peculiarities he ascertains the actual condition of the organ. In auscul- tation of the lungs he employs similar processes, and assists the end organ, in either case, by the use of one of the instruments of precision, known as the stethoscope, brought into general usage by Laennec early in the nine- teenth century. The same idea may have occurred to 117 MORAL PHILOSOPHY OF MEDICINE some close predecessor of the great French physician, but his invention has not been contested. He was probably aware of the use of mediate auscultation among men for a long time, not however, for the purposes of the physician. He may have found mention made of direct auscultation in the.play of King Henry IV., when Prince Harry says to Falstaff .... "lie down; lay thine ear close to the ground and list if thou canst hear the tread of travel- lers." He may also have found a reference or suggestion of mediate auscultation in Rabelais' Pantagruel. That learned physician and cunning satirist, who was so long before Shakespeare in valuing auscultation, relates that Panurge, wishing to ascertain the approach of the patrol- ling guard, placed his sword upon the ground and applied his ear to the pommel; the degree of vibration indicating the nearness of the comers. That surely is a fair example of mediate auscultation with an extemporised stethoscope. However, both Shakespeare and Rabelais must have been anticipated by savages who even now practice direct aus- cultation of the ground to ascertain the approach of enemies or of game, but these had probably learned the trick from the beasts. "He has his ear to the ground," is a commonly used metaphor in praise of an astute, observing, vigilant man. Aside from professional labors, and during recreation, the student will find profit toward the cultivation of his auditive sense by listening to the discourses of those great orators who are full of the spirit of persuasion and blessed with sweet voices in which to utter the most exalted sen- 118 SENSE CULTURE timents with all the splendor of their marvelous elocution, and with such earnestness of manner and such simple, natural, graceful gestures as to gladden also the visual sense of every auditor. He will derive both pleasure and profit intellectually and sensually by cultivating the legiti- mate drama interpreted by able artists, just as he will in the case of the grand opera where he will have great sensual gratification from the classical music of the nine- teenth century masters and of some of their predecessors. There he will have a good opportunity to exercise those wonderful organs of his internal ear to enable his mental audition to detect and enjoy the sweetest and most deli- cate vocal notes, and to derive the highest degree of pleas- ure from the melody and harmony such as can be evolved only from a great orchestra led by a masterly chief. Nothing is more refining to the senses than good music, justly regarded as a supreme blessing and a great treasure "cheering to the spirits and ennobling to the mind, lend- ing soft blandishment to fascinate all mankind." Much relief is often obtained, from mental anguish and corporal distress, by listening to pleasing musical sounds. Galen, who was a firm believer in the efficacy of this ad- juvant in the treatment of those mental affections which react so injuriously on the body, cited /Esculapius in sup- port of his views; saying that this Grecian physician and bard was in the habit of resorting to music in the cure of such disorders. Ages ago it was ascertained that sweet, soft, gentle vocal or instrumental notes not only appeal to the emotions but sooth the nervous, the sick, the sleep- 119 MORAL PHILOSOPHY OF MEDICINE less, and the sorrow-stricken, and so, in a measure, relieve the consequent bodily suffering. When the harper David had played and sung to him, the distressed "Saul was refreshed and was well." In advising music as a remedy for melancholy, Burton said that "it hath been prescribed to exhilarate a sorrowful heart, to divert those fixed and intent cares and meditations which, in this malady, so much offend " Music has also been suggested as a lullaby to soothe the auditive sense of the dying as exemplified in the case of Henry IV.: "Let there be no noise made, my gentle friends; Unless some dull and favorable hand Will whisper music to my weary spirit." And in the case of Queen Catherine, "Cause the musicians play me that sad note 1 named my knell, whilst 1 sit meditating On that celestial harmony I go to." There is another kind of music-weird, loud, and bois- terous-which has anything but a quieting effect and is suited to a disorder requiring for its cure the greatest bodily activity. It is said to have been very successfully employed, during the sixteenth century and later, in the southern part of Italy. This peculiar music was resorted to when an individual was stung by a tarantula, and was played in such measure as to compel him to dance until he fell down exhausted and covered with sweat. The cure was effected purely by the quick elimination of the 120 SENSE CULTURE venom chiefly through the sweat-glands, but was believed by the people to be due to the magical character of the music. Those who have heard the tarantella well played, fully comprehend what its effect must have been on the mind of an ignorant and superstitious peasantry. Theophrastes asserted that skilfully modulated notes upon the flute would cure those bitten by vipers, and Democritus made the same statement. However, they did not suggest that such musical sounds had excited the bitten persons to active movements, as in dancing. It does not seem necessary to enter into further par- ticulars respecting the cultivation of the visual and audi- tive senses because surely the listeners will fill the defi- ciences of the foregoing merely suggestive remarks, and will supply abundant examples illustrative of methods of procedure to effect the desired object. The closely related tactile, olfactive, and gustative senses, grouped together for the convenient discussion of their cultivation, will be the subject of the next conference. 121 VIII TACTION, OLFACTION, AND GUSTATION The tactile sense-Its nature and diffusion-All the other senses modifications of touch-Sensitive apprehension, sensibility, and sensation; their signification-The achievements of man through cultivation of the sense of touch-Some of the modes of culture of direct and of mediate taction-Olfaction culture -The olfactive cells-The specialization of odors-The game of perfumes-Taste culture-The seat of gustation-The five savors-The concurrence of the tactile and olfactive senses essential to perfect gustation. Each section of this conference will contain a brief statement of anatomic peculiarities a right conception of which is essential to the adaptation of certain modes of culture of these several senses. The tactile sense, perhaps more than any of the others, needs the earliest cultivation. It is brought into requisi- tion with such great frequency, and is so closely associated with the rest, that without its intervention they would be of little use. Its powers are well shown in those cases where the other senses have been destroyed. By touch, hard, soft, rough, smooth, we do discern: " By touch, sweet pleasure and sharp pain we try," said the sixteenth century poet Sir John Davies. He could go no farther than to declare charmingly these simple facts, owing to the state of knowledge in his time. But 122 TACTION, OLFACTION, AND GUSTATION even to this day no entirely satisfactory explanation is given of the nature of the power of discrimination by mere touch of the hard from the soft, the rough from the smooth, the pleasing from the painful. If to the touch corpuscles there be accessory organs for the specialisation of these different conditions they, as yet, are undiscovered. There are, however, under the skin and elsewhere, little bodies endowed with the faculty of receiving impressions of weight and pressure. The other cutaneous impressions, such as those of the sensation of cold or heat, of pleasure or pain, are in the category of general sensibility. Modern teachers are generally agreed that the tactile sense, like the other four, is seated in an apparatus con- taining among its organs one which is endowed with a special sensibility that does not exist elsewhere, and that this organ is the receiver of certain impressions; its nerve- trunks being the transmitters of these impressions to a particular brain center and diffused to cause a general sensation of pleasure or displeasure. Thus teachers re- strict, to the five senses, the application of the word sense which is the faculty of sensitive apprehension; of the word sensibility, general or special, to the susceptibility to impression upon the sensory nerves; and of the word sen- sation to the impression made on any part of the sensitive organism; taction, vision, audition, olfaction, and gusta- tion being each the function of its special apparatus. The thinker who asserted that "all the senses are but modifications of touch," thought not in vain, for, the rays of light touch the eye to excite vision, the waves of sound- 123 MORAL PHILOSOPHY OF MEDICINE carrying air touch the ear-drum to cause its vibration and compel audition, the fumes of odorous things touch the olfactive membrane to assure smell, and the savory par- ticles of food touch the gustative bulbs to effect taste. Surely, therefore, Wallace's expressed thought is in accord with Creech's dictum--borrowed from Lucretius' verse: T anger e enim aut tangi nisi corpus nulla potest res-that "nothing but body can be touched or touch"; sunlight, air, fumes, and savory particles being all material bodies that touch and are touched. Without touch-that impelling stroke, that first tap which set matter in mo- tion-the other senses would be absolutely inoperative. Although each sense apparatus derives its name from its function, it contains, besides the organ of special sensi- bility, other organs which are endowed with the faculty of distinguishing particular properties of different ob- jects; as in the case of the sense of vision with lenses for its adjustment, with its sensitive diaphram the iris, its purple pigment, its retinal rods and cones for the deter- mination and regulation of the quality and quantity of light admitted in the eye, and the discrimination of colors; as in the case of the sense of smell with peculiar cells in the yellow region of the nasal mucous membrane for the characterization of odors; as in the case of the sense of taste with its supplementary tactile organs for the dis- tinction of consistence, pungency, and temperature; as in the case of the sense of hearing with its several organs for the appreciation of the direction, distance, and modula- tions of sounds; and, lastly, as in the case of the sense 124 TACTION, OLFACTION, AND GUSTATION of touch with its subsidiary organs for the recognition of pressure, weight, temperature, etc. These supplementary organs are varietal, not specific like the organ of special sensibility in the sense apparatus, and cannot, in reason, be designated special sense organs. The apparatus of touch, unlike the other four which are confined to the head, is spread throughout the cutaneous envelope of the body and some of its mucous membranes, and exists in its muscles and tendons, in its joints and bones. Its organs of special sensibility receive the im- pression of contact with extraneous objects together with their degree of softness or hardness, smoothness or rough- ness and transmit it to the perceptive cerebral center, while the concurrent varietal organs convey the sensation of cold or heat, pressure or weight, to the center of percep- tion. It is clear then that there is no sense but a sensa- tion of cold or heat; no sense but a sensation of pleasure or pain; no sense but a sensation of pressure or weight; no sense but a sensation of hunger, thirst, suffocation or lassitude, etc., etc. Man only can touch delicately with his lips, the tip of his tongue and the ends of his fingers which are furnished with a great wealth of tactile corpuscles embedded in the cutaneous papillae, varying much in numbers in individ- uals as well as in different parts of the body surface. Not all men, however, can possess the same degree of tactile delicacy. The greater the number of corpuscles and the longer the cultivation of the sense, the more delicate the touch, extending even to the extremity of the nails. 125 MORAL PHILOSOPHY OF MEDICINE The sensibility to pressure and weight exists throughout the cutaneous surface and even as deeply as the muscles and the interior of the body. This sensibility is mani- fested through the aid of certain little organs discovered by Vater and described, more than a century later, by Pacini; these bodies seated in the ambient connective tissue and having terminal nerve-fibrils in their interior are endowed with the faculty of receiving impressions of weight and pressure and of transmitting them to the touch center in the brain. The sensation of weight is cul- tivated, in the hand, to the extent of enabling the trades- man to tell readily the value of small coins without the aid of vision and, the artisan to estimate closely the weight of heavy bodies. The sensibility to cold and heat is also disseminated throughout the body surface, more markedly in some parts than in others.* Extremes of temperature, how- ever, cannot be discerned by the human skin; the sensa- tions produced by excessive cold or heat in such cases being identical. When the nose or ear is exposed to a very low temperature there is at first a tingling sensation in the part, but as soon as it is frozen, all sensation ceases. The person is unaware of the condition until his attention is called thereto, and the moment the affected part is thawed there is in it a sensation of burning pain. That the tongue bears a lower degree of cold and a higher degree of heat than other parts of the body is daily exemplified during refection. The iced beverages so agreeable to the * Landois is said to have discovered a thermic center. 126 TACTION, OLFACTION, AND GUSTATION buccal cavity, and the hot liquid and solid tasty aliments so well borne thereby are intolerable to the sensibility of the hand. The sensation of fatigue after violent exercise belongs entirely to the category of general sensibility. Internal sensations are those felt generally without the interven- tion of the impressions of any sense apparatus; they are sometimes styled sentiments, or needs. By the thorough cultivation of the sense of touch, man has achieved some of his greatest works in mechanical, architectural, ornamental, pictorial, sculptural, and medi- cal art, whenever he has associated mind and action. No man can ever attain eminence as a medical artist whose touch corpuscles are few, whose Pacinian bodies are scarce, whose perceptions are blunt, and whose "fingers are all thumbs." Even those whose end-organs of touch are fully developed in quality and quantity cannot expect satisfactory results without long training of these organs. While learning the anatomy of the skeleton, students will do well toward the exercise of the tactile sense by carrying in the pocket and constantly fingering the dry carpal bones of both sides until by touch, unassisted by vision, they are able to identify each particular bone. At first the bones of the right side may be put into the right pocket and those of the left into the left hand pocket, then the order may be reversed, and finally they may all be mixed and carried in the right and later in the left pocket, to be specialised as before. After such per- sistent exercise of the sense, the finger tip of either 127 MORAL PHILOSOPHY OF MEDICINE hand will discern almost invisible hard grains, and even the particles of the so-called impalpable powders may be distinctly felt by him who has cultivated highly this direct or immediate taction. But indirect or mediate taction also should be practised; by beginning with needle dissection of minute objects; following this by the use of* slender metallic probes to detect bare bone in deep cloacae; then by the sound or searcher to disclose the slightest grating of fine gravelly matter; by the lithotrite to feel and seize, in a deep cavity, calculous concretions or frag- ments as small as two or three millimeters, or small hard or soft foreign bodies; and by many other modes of medi- ate exercise of the sense as will naturally occur to the earnest laborer. The walking stick too, may be used to advantage in the practice of mediate taction, so that very small objects upon the ground may be readily recognized, as in the case of the blind man whose stick performs so well the office of a long antenna with which to guide his slow, cautious steps. Among other means of exercising taction are prac- tises on musical instruments, such as the violin and guitar, or the more delicate wind-instruments such as the flute and oboe. The guitar is available only for direct taction. With the violin, both direct and mediate taction can be exercised, whilst the wind as well as the stringed instru- ments exercise also the auditive sense. By these and other kindred exercises, the student's hands are lightened and his touch becomes so delicate that his handling or his examination of patients is ordi- 128 TACTION, OLFACTION, AND GUSTATION narily almost painless to them, whilst he is able to per- form intricate operations without serious injury to adjoin- ing parts; his tactile corpuscles having become exquisitely alert and his Pacinian bodies responsive to the slightest pressure. How glad then he is when he has perfected that much desired physical and mental taction, the tactus eruditus, that gentle, delicate, discerning touch which has added so much to his accomplishments! And how highly gratified when characterized as a man of tact, and reflects that the word-builders had to borrow from that wonder- ful sense the term best adapted to express the idea they sought to convey of that keenness of perception, of discern- ment, which gives a man the greatest adroitness in saying or doing the proper thing at the right time and place! Figurative language is indeed very much indebted to this and the other senses. Of the olfactive sense, it may be said that the student is wise who pays due attention to its cultivation, as he will be obliged so frequently to bring it into play in his daily duties to the sick. It is incumbent upon him to learn to specialise quickly the smells that arise in some sick-rooms, in order to promptly remedy their evils; these odors being almost as injurious to the well as to the sick. Among them the foulness of linen, impregnated with the excretions of sick infants, retained too long in the nursery; the stench of gangrene, of sloughing malignant growths, and of any- thing else in a putrid state; the odor of cats' excretions, or of infection-carrying mice; and very many other smells that belong to disease-breeding objects in a state of decom- 129 MORAL PHILOSOPHY OF MEDICINE position. The olfactive sense is the advanced sentry of the physician. The moment the door of a house is opened to him, his nose is in action and sure to detect and charac- terize, even through the fumes of burning pastilles, any odor peculiar to putrefaction or to some other noxious thing. To cultivate this sense to advantage, he should have clear notions of the nature and workings of the olfactive apparatus whose organ of special sensibility consists of innumerable filaments, derived from the ganglion of the nerve of smell, spread upon the surface of the "yellow region'' of the mucous membrane in the upper half of the nasal cavity. Among the cylindrical epithelial cells of this yellow region are many fusiform cells attached to terminal olfactive nerve fibrils. The office of these cells is said to be the reception of odors and their conveyance to the perceptive center. The impressions thus received in the yellow region are transmitted to the ganglion at the end of the olfactory nerve and thence to the olfactive brain center. That an odor may make its right impression upon the olfactive end-organ, it must be inhaled slowly. Only thus can its diffusion through the yellow region be assured; a moderate degree of heat and moisture being requisite for complete olfaction. The odor of many plants and flowers is better appreciated in moist than in dry air, but an excess of moisture is fatal to delicate olfaction, especially during long continued fogs, or when the nasal membrane is sodden and swollen from what is called a cold in the head. 130 TACTION, OLFACTION, AND GUSTATION The lower half of the nasal cavity, being endowed only with general sensibility, takes no part in olfaction but stands guard against offensive foreign intruders which it sneezes out. The student may learn a useful lesson about odors from the omniscient Dogberry who appears to have been the first myrosophist to discover that "comparisons are odorous"; that an odor is a perfume and a perfume an odor; and that certain odors are good and others bad, some offensive to man and pleasing to beast, and vice versa. The relativity of odors was as clear to him as to the many writers who have used the word figuratively, as in the phrases, X .... is in good odor; Y . . . . is in bad odor; the odor of sanctity; the smell of heresy; the perfume of praise, etc., etc A double meaning to the phrase-"comparisons are odorous"-was apparently intended to be conveyed by him who used so skilfully the language most appropriate to the characters he so admirably pictured. The first, odorous for odious, is purely satiric, whilst the second is figurative as well as satiric; comparisons being odious are odorous, that is to say are in bad odor. The text very clearly shows*the first to be of purely satiric meaning, the second both satiric and figurative; the boors of the time being unwashed, unkempt, reeking with foulness and uttering uncouth speech with malodorous breath. His wide range of observation made the Avon philoso- pher aware that each vegetable species, each animal species, has its own peculiar perfume, and that many mineral sub- 131 MORAL PHILOSOPHY OF MEDICINE stances emit odors by which they are often characterized. In the case of man, he knew that each individual has his own odor which is so readily distinguished by domestic animals such as dogs who remember long the smell of their masters and even of their masters' friends; and he may have suggested that individual animals of the same species have their peculiar smells recognizable mainly by their own kind. Although perfume-from per, through, and funius, smoke-used in strict accord with its etymon, implies redolency, the effusion or exhalation of odorous vapors, fetid as well as fragrant, it is ordinarily employed to designate those fumes which are agreeable to human olfac- tion. But certain effluences which give great pleasure to many persons, are extremely offensive to the sense of smell of others and even cause nausea and faintness, or otherwise sicken the idiosyncratic; as for instance the strong odor of the tuberose, of the oil of bitter almonds, of the attar of roses, of musk, of powdered ipecac or of opium, etc. A thorough knowledge of the effects of offensive odors is essential to the physician, that he may speedily remove the cause, and this knowledge can only come from early exercise of his off active apparatus; beginning with agree- able perfumes for contrast with foul odors. A fair example of the opposite effect of different scents on two individuals whose tastes and habits do not cor- respond, is that related of the encounter of an Athenian woman and a Spartan woman. The penetrating odor of 132 TACTION, OLFACTION, AND GUSTATION a rancid unguent exhaled from the Spartan's hair was extremely offensive to the delicately perfumed Athenian whose refined essences were equally repellant to the Spartan woman, so they simultaneously turned away in disgust. Many perfumes which are pleasing to olfaction are very noxious, as the vapor of chloroform and of hydrocyanic acid; while others are both offensive to smell and death- dealing, as the fumes of sulphur, of light carburetted hydro- gen, of nitric and hydrochloric acid, of chlorine, and of other deleterious substances. It is well known that many persons who perish in great conflagrations are first ren- dered insensible and are suffocated by malodorous* gases before their bodies are burned. Such is sometimes the fate of victims of volcanic eruptions, even when distant from a crater. Some perfumes have an exhilarating fragrance, as that of the ethers of wines, of pelargonic, oenanthic, ethylic, and of other very volatile ethers. The delightful aroma of many fruits and flowers is much intensified by slight heat, or by friction or pressure. While heat brings out the latent fragrance of certain fruits and of other edible substances, carbonisation soon destroys their new-born perfume, and putrefaction so counteracts the most deli- cious odor emitted by sweet-scented flowers and fruits as to cause a sickening stench. It is therefore important that the student acquaint himself with and remember the different odors of saprophites and infective micro- organisms. 133 MORAL PHILOSOPHY OF MEDICINE Certain perfumes are developed only by combustion, such as some resinous gums so much used in religious cere- monies, such as those narrow strips of oriental paper which, when burned, emit fragrant fumes that soon per- meate the ambient air, and such as the fumigating pastilles now in common use. The Japanese are said to indulge, for exercise of olfac- tion and for recreation, in the luxurious "game of per- fumes" which consists in igniting bits of differently scented resins whose fumes are inhaled to test the olfactive per- ception and sensual memory of the players, six in the game. Whoever specialises the greatest number of odors receives a prize. Mineral and vegetable substances of strong odor were anciently used to counteract stenches, to purify lazarettos, and to fumigate and disinfect plague-stricken regions, and for the embalmment of the dead. The great majorities of perfumes are but feeble disinfectants; their strong smell overpowers some foul odors without destroying any germs, and therefore the purpose of their use is not fulfilled. During the great plague in Athens, the story of which was so well told by Thucydides, wood was piled up in different parts of the city and burned for purifying the air with the perfume of the wood and thus checking the further diffusion of the epidemic. In the present light of science, it is clear that any good accomplished by such a process must have been through the destructive effect of the hot smoke upon the infective organisms which were 134 TACTION, OLFACTION, AND GUSTATION causing the disease. A comparatively modern example of the good effect of intense heat and smoke in arresting the fatal pest, is afforded by the occurrence of an extensive fire, in London during the seventeenth century, which destroyed nearly all the habitations in the infected dis- tricts and put an end to the pestilence which threatened to depopulate the town. The filth of the capital had always been such as to shock the olfaction of visitors. Erasmus declined a flattering invitation from Henry VI11. to establish himself in the great city on account, as he afterward said in his letters, of the "filthiness of the streets and the sluttishness within doors. The floors, commonly of clay, are strewed with rushes under which lie unmolested an ancient collection of lees, grease, fragments, bones, spittle, excrements of dogs and cats, and everything that is nasty." Even in the Elizabethan period, the uncarpeted rooms of the great had to be sprinkled with liquid fragrant perfumes after the foul straw or rushes had been removed. Such filth in the homes of the rich and poor served as a medium for the pullulation of disease-breeding germs which spared neither lord nor peasant. It is plain then that the consequences of neglecting olfactive cultivation are sometimes likely to be of the gravest. The gustative sense, one of the most precious endow- ments of the Creator to the creature, is granted to nearly all animated beings, but man alone is able to cultivate it to a high degree. Probably the first taster seeing an object, such as he had watched an animal in the act of 135 MORAL PHILOSOPHY OF MEDICINE ingesting, tried it, but it was malodorous, nauseous, un- savory, so he rejected it; and finding one of another kind in which he perceived fragrance and sapidity after bruis- ing it in his mouth, swallowed it because of the pleasing buccal sensation it produced. Upon a like happening is based the assertion that gustation is the perception and distinction of savory and unsavory qualities of ingesta. To cultivate this sense advantageously, the student should have a clear understanding of the nature and seat of the end organs of gustation, remembering the part taken by olfaction and taction to complete the act of tasting. He should have correct notions of the savor and odor of alimentary substances in the crude state, and of the modifications of these savors and odors by cookery and by condiments. And should eat slowly, deliberately, thoughtfully, in order to be able to judge rightly of the gustible and appetising qualities of edibles. The pre- liminary information needed to effect this cultivation will be detailed in the following paragraphs. A glance at the derivation of gustation and taste may be of service to the student in his use of these terms; one from gustare to taste, and the other, intensively, from tangere to touch and formerly employed synonymously with to test, to try, to feel. " . ... Come, let me taste my horse Who is to bear me like a thunderbolt. . . . ." - i Henry IV., iv. \. i 19. " Taste your legs, sir; put them in motion." - Twelfth Night, Hi. 1.87. 136 TACTION, OLFACTION, AND GUSTATION In French the word gout alone is used for taste while in English.are the two words gust and taste to convey the same idea; and therefrom is based a liberal stock of other nouns, adjectives, etc. Thus from gust are builded gusta- tion, gustative, gustatory, gustable, gustible, gustful, gust- less, ingustable, disgust, disgustful, disgusting; and from taste, tasting, tasty, tasteful, tasteless, etc. Then follow certain expressions connected with gustation and relating to special qualities, as sapidity, saporific, sapid, insipid; savor, savory, unsavory; flavor, flavoring, flavorless. Strictly, to taste is to test, try, feel, with the tongue any substance put into the mouth with a view of ascertain- ing whether sapid or insipid, pleasing or otherwise; the perception of these characters being seated in the gusta- tive center in the brain whence is reflected the general sensation of pleasure or displeasure. Taste, like many other words pertaining to the alimen- tation of man's body is largely used figuratively, as in the expressions good or bad taste or simply taste or its want, in written or spoken language, in deportment, in dress, in art, etc.; "De gustibus non est disputandum" being applied to both the original term and its figurative usage. For instance, an aliment which is gustful to one may be disgustful to another individual. A particular work of art may give pleasure to a simple unskilled ama- teur and fail to satisfy the aesthesis of vision of a truly good judge of art. Some forms or colors which are pleas- ing to the many are offensive to the few whose visual sense is highly cultivated. 137 MORAL PHILOSOPHY OF MEDICINE The seat of gustation is at the base and sides of the tongue; the base being the region of the caliciform-papillae and the sides the region of the fungiform papillae. The exquisitely delicate filiform papillae, disseminated upon nearly the whole upper surface of the tongue, being purely tactile. Besides ramifications of twigs from the glosso- pharyngeal nerve and lingual branch of the trigeminal, the caliciform papillae contain minute gustative bulbs dis- covered by Schwalbe and Loven in 1867. These gusta- tive bulbs exist also in the fungiform papillae. Thus the chain of specialising bodies in the sense end-organs is com- plete, from the retinal rods and cones, the tactile corpuscles and Pacinian bodies, the olfactive cells in the upper yellow region of the nasal mucous membrane, to the organs of Corti in the internal ear. Some experimenters have reached the conclusion that there are but two veritable savors recognisable through the gustative bulbs, namely: the sweet and the bitter, while others have identified three additional savors; the saline, the alkaline, and the acid. But all reject the idea of acrid savors which really result from the mechanical action of acrid substances upon the tactile papillae, and ignore the so-called aromatic savor which belongs to olfaction. Nevertheless the concurrence of the tactile and olfactive senses is essential to perfect gustation and to the full enjoyment of delicious aliments. It is an interesting fact that professional wine-tasters use olfaction quite as much as gustation in testing wines, and do so by slow inhalations in order that the vinous 138 TACTION, OLFACTION, AND GUSTATION fumes may linger in the region of the olfactive cells and abundant twigs of the nerve of smell; finally rinsing the mouth with the wine, that it may act upon the filiform and other papillae of the tongue, to ascertain its strength and sweetness, bitterness or acidity. The tea-tasters, also, use olfaction to determine the aroma of the dry leaves, crushed and warmed in the palm of the hand, before inhaling the prepared infusion; the final test being made in the mouth to judge of the degree of bitterness, astringency, and other properties discover- able by gustation. Tasty aliments are often designated palatable although the palate is passive in gustation; its office being purely mechanical and serving as a hard fixed surface against which the tongue bruises the food to express and diffuse sapid particles for quick solution by the saliva without which there would be no gustation of solids. The other parts of the buccal cavity possess no more than tactile properties. Experience teaches that the only truly gustible aliments are those containing bitter, sweet, saline, alkaline, or acid principles. Hence the free use of condiments of such nature in good cookery, and of pungent condiments in moderation to stimulate all the papillae. Fats are gustible from their slight acidity and from the contained sodic chloride. Sweet and acid fruits are always enjoyable whilst the neutral are insipid, mawkish. Bread without salt would be practically tasteless. Distilled water is insipid but becomes sapid when a trace of salt or sugar is 139 MORAL PHILOSOPHY OF MEDICINE added. Wines are gustible by reason of the sugar or other sapid principles therein contained; it is their aroma that gives the greater pleasure, through olfaction. Very dry wines and spirits act mechanically upon the papillae, and their ethers are enjoyed by olfaction. Rum is gusti- ble owing to its sweetness. Beer would be insipid but for its bitterness. Taste then, with its closely associated olfactive and tactile senses, is regarded, gastronomicly, as the special and general pleasure evoked by the perception and special- isation of the crispness, of the succulence, sapidity, and perfume of aliments; and figuratively as a judgment of the beautiful, the sublime and the picturesque. The physician should familiarise himself with the taste, smell, consistence, and other characters, not only of the substances just mentioned but of the majority of the drugs which he may have to prescribe. High cultivation of the sense of taste is of imperative necessity to him, that he may know the true value as well as the dangerously enticing qualities of the dainty dietary of his convalescing patients, and that he may authoritatively impress upon them the importance of temperate use of delicacies, and give them due warning of the ill effects of indulging their appetite to excess. The interdependence of the senses is such that they should all be under constant exercise, but to touch, the chief of the whole brigade, the greatest share of attention should be bestowed. The impossibility to do justice to the very interesting 140 TACTION, OLFACTION, AND GUSTATION subject of sense culture, in its divers aspects, through two brief conferences, must have been fully realised by the auditors. But there is a lingering hope that these short sketches may evoke general attention to the importance of long continued sense exercise, and induce all physicians to examine at leisure the many questions which it involves. 141 IX EVOLUTION OF MEDICAL MORALS A summary of the history of the evolution of medical morals- Beginning of the indoctrination of individual obligations- Reciprocity a word of command-Justice, mercy, generosity, hope, faith, and charity the fundamental maxim of all sys- tems of good morals-A glance at the Hippocratic oath, law, iatrium, aphorisms, and prognostics-Collocation of moral precepts by Doctor Thomas Percival-The American system of medical morals, its origin. The student, being desirous to learn certain special rules of conduct adapted to his future labors in the prac- tice of medicine, will better understand and appreciate their import by giving heed to a statement of the source of these rules and of their early observation. For this end, a brief exposition of the history of the evolution of medical morals will be offered as a preliminary answer to his queries. This history, traced from the inception of the indoctrination of individual obligations, and of the great principle of reciprocity which is the very nucleus of every system of good morals, supplies a vast abundance of materials for serious thought; hence the following sum- mary thereof intended as a mere suggestion of the direc- tion which may be taken in the investigation of the sub- ject by earnest students of the moral philosophy of medicine. 142 EVOLUTION OF MEDICAL MORALS It was probably long after man emerged from his state of savagery that some sage began to promulgate the maxim that great happiness is attainable only through good deeds, and it is likely that he told, with illustrative examples, what acts were to be regarded as good, and what as evil. Having thus established a standard of judgment, it is more than likely that this same sage, by eloquent preachments, attracted great crowds of people and succeeded in impressing his criterion and some salu- tary precepts upon the minds of his closer followers who, with additions, transmitted them to new disciples who, in turn, promulgated them, and so from generation to gen- eration, ages before the time of Confucius who recorded many of them among which was the maxim relating to reciprocity. "Tsze-Kung asked, saying, 'is there one word which may serve as a rule of practice for all one's life?' The master said, 'is not reciprocity such a word?' What you do not want done to yourself, do not do to others." This negative mode of expression in the Confucian Analects is a mere suggestion of reciprocity which is also distinctly implied a century later, in the oath and law of Hippocrates, while it appears in the form of a positive, divine command in the Sermon on the Mount- ''Therefore all things what- soever that ye would that men should do to you, do ye so to them: for this is the law and the Prophets." It is plain that reciprocity, used in this sense, is a word of command, and that it necessarily involves justice, mercy, generosity, good faith, much hope, and great charity. It is equally 143 MORAL PHILOSOPHY OF MEDICINE plain that the present moral laws, based, as they are, upon these virtues, were not made by any single individual, but are the results of the researches of many moralists who have added to the records of good actions, good customs, which, by others, have been collated systematically, and finally adopted as a whole by associations of men, just as civil laws have been thus compiled from the most ancient usages, and moral laws from good customary practices of men; the word morals being derived from mores, customs. Justice, mercy, generosity, hope, faith, and charity, con- stituting, as they do, the broad basis of good morals, need constant cultivation by all who love to labor for the weal of humanity. Those assuredly enjoy the fullest measure of happiness who are scrupulously just, ever merciful, and always generous; hopeful of the good to come of justice when faithfully tempered with mercy, generous in its inter- pretation, and charitable in its administration. Be just, merciful, generous, hopeful, faithful, charitable, may well stand as a fundamental maxim of any system of good morals. Any deviation from this sublime maxim must resolve itself inevitably into be unjust, unmerciful, ungen- erous, hopeless, faithless, uncharitable, which is the creed of the wicked. The earliest principles of conduct of the physician known to have been reduced to writing are those set forth by the Father of Medicine in his Oath, Law, 1 atrium, Aphorisms, and Prognostics. They were the precursors of the many excellent precepts that have been expounded by modern medical moralists, and that have served so well in the 144 EVOLUTION OF MEDICAL MORALS development of the moral and professional characters of physicians, and in raising the standard of scientific ac- quirement. He was indeed inspired with the noblest and most exalted sentiments when he composed these sub- lime and immortal documents! The Oath, opx&s, which the master himself took, is regarded by some commentators as "an indenture between master and pupil, and as evidence that very anciently the profession was organized into a regular corporation whose members were bound by oath to observe its regulations, and having qualified instructors in the art." Careful examination of this interesting work reveals in it many suggestions of reciprocity which do not appear at a casual glance. The first clause of the first sentence is the oath proper, phrased, of course, in accordance with the tenets of poly- theism, when an oath was as sacred as it is at the present time. An oath was exacted of every aspirant to a medical degree by the school of Salernum and by the earliest schools of France and of other European countries, but of late years the wise observance has been sadly neglected. The old law maxim--"There is no stronger bond among men than an oath"-may well be applied to the young men who take the modified Hippocratic oath which so binds them in fraternity and attaches them to Alma Mater in filial love and reverence, to the profession in loyalty, and to the sick in devotion. The second and succeeding clauses of the first sentence of 145 MORAL PHILOSOPHY OF MEDICINE the Hippocratic oath constitute the beginning specifica- tions, and provide that the pupil shall regard his master in the light of a parent; share his substance with this master in case of distress from accident or sickness; relieve his necessities in the event of permanent disability; look upon his offspring as brothers and teach them the medical art without fee or stipulation; and impart a knowledge of the art to his own sons and to disciples bound by an oath and a stipulation, but to none others. In those ancient times, the profession of medicine passed from fathers to sons, as a general rule, and none others were admitted as pupils unless they bound themselves by oath and stipulation to abide by the law and regulations of medicine. The second sentence, which relates to regimen of patients, shows how important the master regarded the question of alimentation of the sick. Diet, said one of his com- mentators, "was one of the most efficient weapons he wielded in his combats with disease, and was that part of his system on which he chiefly prided himself, as being in a peculiar manner his own invention,'' The first clause of the third sentence-" I will give no deadly medicine to any one if asked, nor suggest such counsel-tends to show that self-destruction by poison was common in his time, and that unprincipled physi- cians accepted bribes for administering poisons. Many self-murderers even now are wont to seek euthanasia by hypnotic or by quick acting poisons. A few years ago, a man of wealth, tired of life, offered to his physician a 146 EVOLUTION OF MEDICAL MORALS large sum of money if he would procure him a painless death by some poison; suggesting prussic acid. On the absolute refusal of the physician, who characterized such an act as the heinous crime of murder on the part of both, he retired, apparently satisfied that the rebuke was just, but in a short time was found dead by his own violent hand. He had never shown the least sign of madness. The second clause of the third sentence-"and in like manner I will not give a woman a pessary to produce abortion." This is perhaps the earliest record of the true physician's condemnation of a crime so common in all times among civilised nations. Though so long ago char- acterized by the profession, by the church and by the state, as cruel murder, it is still of daily occurrence in every land on this earth. The perpetrators are so seldom punished that the wretches who ply the vile trade boldly advertise their wares and too often find means to evade the law. The fourth sentence-"With purity and with holiness I will pass my life and practice my art"-is sufficient evi- dence of the noble aspiration of the virtuous Master who devoted such a long life in teaching his art and healing the sick. However, like many other good men, he did not escape calumny, for his virtues had excited the envy of the wicked. The fifth sentence-" I will not cut persons laboring under the stone, but leave this to be done by men who are prac- tisers of this work"-seems to have perplexed some of the commentators who regarded the proscription as singular 147 MORAL PHILOSOPHY OF MEDICINE without taking into account the fact that wounds of the bladder were formerly believed to be extremely danger- ous and even fatal. Hence the general unwillingness to undertake the operation. It was partly owing to this that the Master forbade his disciples to perform it, and partly that the work was already in the hands of ignorant charlatans who were also practisers of orchidectomy. In- deed, until the beginning of the sixteenth century the performance of this operation was confided by the people to disreputable persons, and regarded by the profession as disgraceful. The seventh sentence is of great moment to the patient as well as to the physician. There will be occasion for reference to it in the next conference. It is as follows: "Whatever in connexion with my professional practice, or not in connexion with it, I see or hear, in the life of men, which ought not to be spoken of abroad, 1 will not divulge, as reckoning that all such should be kept secret." This oath, which has been variously modified, is now required-but by too few medical colleges-of each candi- date for graduation, in something like the following form: 1 solemnly swear, by the Lord God, that I will keep this oath and this stipulation. I. To reckon those who have taught me the science and art of medicine dear to me as foster-parents. 2. To regard as brothers my medical colleagues, and to revere my seniors. 3. To be loyal to the profession, and to labor for the advancement of medicine. 148 EVOLUTION OF MEDICAL MORALS 4. To obey the laws enacted by the profession for the government of its members. 5. To devote my best abilities to the relief of human suffering, to the prevention of disease, and to the promo- tion of public health. 6. To eschew vicious habits and lead a pure life. 7. To endeavor to deter the misguided, mentally dis- eased, from self-destruction. 8. To condemn the production df abortion as a cruel murder, and never to resort to it under any circumstances whatsoever. 9. To observe the strictest secrecy regarding whatever, in connexion or not in connexion with my professional practice, 1 see or hear which ought not to be revealed. 10. To keep this sacred oath as long as I live. The Law, vopos, is evidently complementary to the Oath. It is given in five sections in the translation of Adams whose remarks thereon are as interesting as in- structive. The able commentator thought that insomuch as the Master apparently wished to sketch the ideal of the perfect physician in order that he may be distinguished from the pretender, the production might have been fitly styled The Standard, for it states with much precision the advantages requisite for the acquirement of eminence in the art of medicine. The first clause of the first sentence of the first section- "Medicine is of all the arts the most noble"-is true be- cause medicine ministers to what is most precious to man, namely: the preservation of health and the relief of men- 149 MORAL PHILOSOPHY OF MEDICINE tai and physical suffering. It is ennobling to its votaries who practice it intelligently and conscientiously and strive to surmount the many difficulties which so often arise in the diagnosis and treatment of diseases. These practisers of the noble art are further ennobled by their devotion to the sick, by their self-sacrifice, by their contributions to the advancement of the science and art, and by the many dangers they brave in more ways than can be dreamed of by the laity. The second clause-"but owing to the ignorance of those who practise it, and of those who, inconsiderately form a judgment of them, it is at present far behind all the other arts"-proclaims a lament which is equally vented in these days. In ancient times the practice of medicine was in the hands chiefly of ignorant pretenders who would not, even if they could, advance the art; hence it was far behind all the other arts. Although the learned have since increased numerically, the crafty pre- tenders have never proportionately decreased, and still continue to prey upon public credulity, chiefly because the people has never been properly enlightened by the profession as to the real nature and aims of legitimate medicine and as to what constitutes the true physician. Even in these days, when a charlatan is characterized as a cheat, an imposter, the populace is wont to heed the rogue's plaint of persecution, and to attribute any denun- ciation of his evil deeds to professional jealousy, for the uninformed make no discrimination between the true and the spurious; all having or assuming the title of doctor 150 EVOLUTION OF MEDICAL MORALS in medicine being the same to the thoughtless, one as good or as bad as the other. The masses are always daz- zled by what, in their faulty judgment, they regard as marvelous and believe the mendacious, however grossly absurd may be their pretentions and promises of cure, or extravagant and dangerous their means of treatment. Hence it is that charlatanism prevails as it has always prevailed and thriven among the unthinking and unknow- ing who are in the immense majority on this earth. It is therefore incumbent upon each loyal member of the pro- fession to give proper information, on medical morals, to all his clients, particularly on the reciprocal relations of physicians and their patients, and the public, and thus help to diminish the number of wrong believers. - The second sentence is to the following effect: "Their mistake appears to arise principally from the fact that in the cities there is no punishment connected with the prac- tice of medicine except disgrace, and that it does not hurt those who are familiar with it." The meaning of this seems to be that even a simple reproof may be regarded as a punishment by the sensitive physician for a first offense, but that all chronic offenders are so insensible to censure, so hardened in mind, as to shamelessly disregard the condemnation of their acts as disgraceful. The offenders are picturedinthe third sentence as follows: "Such persons are like the figures which are introduced in tragedies, for they have the shape, and dress, and personal appearance of actors, but are not actors, so also physicians are many in title but few in reality." 151 MORAL PHILOSOPHY OF MEDICINE The second, third, fourth, and fifth sections relate to the requirements for entrance upon the study of medicine, and are well worthy of special examination not only on account of their intrinsic value, but of the simplicity, con- ciseness, clearness, and quaintness of the language and of the similes used throughout. The latrium was the physician's office, corresponding to "The Surgery" in England. In it were kept medicines and all necessary implements for the treatment of office patients. Of the book bearing this title, the first section alone will be cited because therein the Master tells of the best means of accurate diagnosis, effected by the trained senses and clear perception. "It is the business of the physician to know, in the first place, things similar and things dissimilar; those con- nected with things most important, most easily known, and in any wise known; which are to be perceived in the sight, and the touch, and hearing, and the nose, and the tongue, and the understanding; which are to be known by all the means we know other things." In the remaining sections, to the twenty-fifth and last, are the minutest details of the physician's conduct, especi- ally in cases of injuries. The truly great book of aphorisms likewise contains excel- lent rules of conduct of the practicing physician. The first aphorism, though so well known to all readers, will nevertheless be quoted for the benefit of the young. "Life is short, and the art long; the occasion fleeting; experience fallacious, and judgment difficult. The phy- 152 EVOLUTION OF MEDICAL MORALS sician must not only be prepared to do what is right him- self, but also to make the patient, the attendants, and externals cooperate." This brief exordium warns the beginner of the gravity and great responsibility of his undertaking. It first con- trasts the brevity of life and the prolixity of the art, then enjoins prompt decision in beginning treatment, "the time being urgent," and tells of the difficulty of judging cor- rectly owing to the fallaciousness of experience. Besides which it suggests reciprocity in the form of exacting co- operation, and also obedience to directions, on the part of patient, attendants, and externals, such as members of the family. This should always be the chief condition on which the physician undertake the treatment of the sick. The Master's precious book on prognostics, in twenty-five paragraphs, and several of his other books, are also filled with admirable principles of medical conduct. Only the first sentence of the first paragraph of " Prognostics" need be quoted, it is substantially as follows: "It is an excellent thing for the physician to cultivate prognosis; for, by foreseeing and foretelling, in the pres- ence of the sick, the present, the past and the future, and explaining the omissions of patients, he will be the more readily believed to be acquainted with the circumstances of the sick; so that men will have confidence to intrust themselves to such a physician." There could be no better plea than this for the early cultivation of the art of prognosticating, on modern lines, of course. 153 MORAL PHILOSOPHY OF MEDICINE Thus it is apparent, from these five books of Hippocrates as well as from other parts of his works, that enough wholesome precepts could have been extracted and so arranged as to form an excellent system of morals; but his successors were contented, during many centuries, to grope through those writings for information respecting particular lines of conduct. The Salernum school, the early French schools, the English College of Physicians, all had their special moral statutes, but these divers in- complete documents were designed for the government only of members of the local institutions, not for the general profession of medicine. The statutes of the College of Chirurgery of Paris were written in the year 1268 by Jean Pitard. Among these statutes are some which may be of interest to the present generation of physicians, as: The sixth statute which is to the effect that each master in chirurgery shall aid those masters who have become indigent. The twentieth provides that the degree of master in chirurgery shall be conferred only after the recipient shall have taken an oath to observe these statutes. The twenty-eighth relates to the prosecution of charla- tans and all others who may attempt to practise without due authorization. The thirty-ninth condemns the frequentation of charla- tans and of other people in bad repute. The forty-second forbids advertising, to the public, special skill in treatment, orally, by placards, or by any other means. 154 EVOLUTION OF MEDICAL MORALS The collocation of moral precepts for the instruction of beginners in medicine does not appear to have been at- tempted by any English-speaking people, until the ques- tion of its utility and necessity began to attract the atten- tion of some wise physicians. It was undertaken toward the close of the eighteenth century, and was entrusted to a man almost as great in scholarship and erudition as he was in devotion and virtue. That lettered champion of truth and good morals was Doctor Thomas Percival, of Manchester, to whom the profession owes a vast debt of gratitude for his untiring labors in gathering, arranging, and editing, with such sound judgment, and ability, the rules of conduct best adapted to the physician, even of these days although published as far back as the early part (February) of the year 1803. The object of the author was to establish a system of rules, "that the official conduct and mutual intercourse of the Faculty might be regulated by precise and acknowledged principles of urbanity and rectitude." In a letter to his loved son who was about to enter the ranks of the medical profession, he said "It is characteristic of a wise man to act on determinate principles; and of a good man to be assured that they are conformable to rectitude and virtue. The relations in which a physician stands to his patients, and to the public, are complicated and multifarious; in- volving much knowledge of human nature, and extensive moral duties. The study of professional morals, there- fore, cannot fail to invigorate and enlarge your under- standing; whilst the observance of the duties which they 155 MORAL PHILOSOPHY OF MEDICINE enjoin, will soften your manners, expand your affections and form you to that propriety and dignity of conduct, which are essential to the character of a gentleman." What an admirable syllabus of his whole work, and what a superb portraiture of the man's high character and noble aspirations! Forty-four years after the publication of Doctor Perci- val's book, the American Medical Association was organ- ized and at once appointed a special committee consisting of Doctors Bell, Emerson, and Hays, of Pennsylvania; Doctor Arnold of Georgia; Doctor Clark of New York; Doctor Dunn of Rhode Island; and Doctor Morris of Delaware; with instructions to frame a system of morals for the government of members of the Association and for the information of the whole profession and of the public. The committee, after examining many such systems emanating from local medical societies, and finding that they were derived from Doctor Percival's writings, deter- mined to use the English moralist's method as the model for their splendid system of rules of conduct which was so wisely adopted by the National Association. The promulgation of the lofty principles embodied in that priceless instrument has had the much desired effect of greatly raising the standard of medical morals and thought throughout this vast land. Like the Hippocratic oath and law, the national system of medical morals prescribes no penalties for violation of its provisions; the consequence of a violation being sting of conscience or disgrace. It aims, as said Doctor Austin 156 EVOLUTION OF MEDICAL MORALS Flint, its able commentator, "solely at the influence of its rules on the mind, irrespective of any penalties. It is based on the principle that moral rectitude is promoted more by fostering upright sentiments than by the punish- ment of offenses." It tells with precision and lucidity what the physician shall do and what he shall not do, as well as what is derogatory to professional dignity. It prescribes rules of etiquette, and informs clients of their obligations to physicians. Therefore it is a system of laws for the government of physicians and of the people in their relations to physicians. The honorable Committee of 1847 being imbued with the idea that the most acceptable system of good medical morals must necessarily be one consisting of a carefully arranged collection of the most exalted precepts and rules for the guidance of physicians, patients, the public, and the state, in their reciprocal relations, gave the amplest evidence of their great sagacity when they couched these precepts and rules in the elegant language which renders the perusal of the whole composition as attractive and entertaining as are its teachings instructive and edifying; for they knew well that any essay composed in good man- ner and pregnant with useful matter must give information in a style the most pleasing to the aethesis of the reader; whilst a slovenly, dryly and obscurely phrased discourse, though it contain excellent ideas would, in all likelihood, be cast aside half, if at all, read by the majority even of those anxious for information. The admirably pure and exact language of the moral production in question gives 157 MORAL PHILOSOPHY OF MEDICINE it a peculiar charm which delights the scholar, while it serves as a model of excellence for the rising generation of medical writers. The influence it has exerted morally and intellectually upon the profession in this country is verily marvelous. Those least familiar with its provisions and aims have been its worst detractors who have thus given encouragement to designing charlatans who take every opportunity to tell the people that this system of medical morals is "a mouldy, antiquated, illiberal, intolerant, oppressive, inhuman composition of the old school." And the people will believe all this as long as kept in ignorance of the wise, liberal, humane, and salutary provisions there- in contained, particularly those relating to the obligations of patients to their physicians and of the public to the profession. 158 X THE PHYSICIAN AND HIS PATIENT Relations and obligations of the physician to his patients- Prompt obedience to the calls of the sick-Attention, steadi- ness and fidelity-Indulgence to the caprices of the sick- The obligation of secrecy extending beyond the period of professional services-A physician obtaining information in his professional capacity not bound to reveal it in any court of justice-Of necessary and unnecessary visitations to the sick-Gloomy prognostications not to be made within hear- ing of patients-Conduct as regards attendance on incurable cases-The division of responsibility in the management of serious and difficult cases. The subjects of this and the next two conferences will have special relation to the reciprocal obligations of the physician and patient, of the physician and the profession, and the profession and the public. Thus, by the laws of medicine, physicians are bound in devotion to their pa- tients, and patients are bound in obedience to the direc- tions of their physicians. All physicians are bound to observe the laws enacted by the profession, and the pro- fession is under obligation to enact such laws as are best adapted to the government of its members, and is bound to give these members due protection against unjust attacks. The profession is also bound to establish proper sanitary regulations for the weal of the public, and the 159 MORAL PHILOSOPHY OF MEDICINE public is bound, in reciprocity, to make due recognition of the labors of the profession. The junior physician, wishing to know what particular rules of conduct are best adapted to his professional rela- tions with clients, asks that he may be informed of the nature of the rules by which to be guided in the perform- ance of his duties. These rules of conduct are excellently stated, in the national system of medical morals, substantially as follows: The physician is enjoined to be ever ready to obey the calls of the sick; to be imbued with the high character of his mission; to bear in mind that the ease, health, and lives of his patients depend on his skill, attention and fidelity; to unite tenderness with firmness in his deport- ment and so, inspire his clients with respect, confidence, and gratitude; and finally, he is apprised of the fact that the only tribunal to adjudge penalties for carelessness or neglect is his own conscience. These provisions and injunctions, though long known to physicians of experience, have to be frequently re- hearsed for the information of beginners. There can be no doubt of the necessity to tell young physicians of their duty to obey promptly the calls of the sick; that their mission is one of mercy; that the responsibility they incur in the discharge of their duties is great; and that, since their work is generally done in privacy, the only punishment for carelessness or wilful neglect is through the sting of conscience and loss of self-respect. These injunctions and all others in that system are truly enno- 160 THE PHYSICIAN AND HIS PATIENT bling and serve, as says Doctor Percival, to soften the man- ners and expand the affections of the young, and form them to that propriety and dignity of conduct which are essential to the character of gentlemen. How merciful on the part of the physician, how comforting to the patient, when firmness is tempered with tenderness; how noble in the physician to be tenderly firm, and how neces- sary it often is for him to be condescending, that is, to be yielding in minor details so that his authority may be the greater, in important particulars, for the good of the sufferer! And how can he fail to inspire gratitude, respect, and confidence, if he observe these injunctions in letter and spirit? However, the devoted, self-sacrificing physician should not lose sight of the fact that the exercise of his profes- sion affords the only means of gaining his livelihood; therefore it becomes him to place a proper valuation on his services. His loyal clients will think the better of him for his own high estimate of good work which they cheer- fully recognize pecuniarily, and add to this acknowledg- ment many expressions of sincere gratitude which is always the true compensation. The "poor patient" is never dis- missed from the physician's door without being cared for professionally, and without feeling that something has been done for the relief of his distress which so often requires food and raiment besides medicines and even money; all of which are given freely by the physician more frequently than is generally supposed. But it is not just of the community to demand of physicians the devo- 161 MORAL PHILOSOPHY OF MEDICINE tion, to public medical service,of so much of their time and skill without due pecuniary acknowledgment. The injus- tice will cease only when members of the medical profes- sion shall insist upon the same rights and emoluments as are accorded to other professional men in public service. Howsoever great may be such emoluments, they can never be an adequate compensation for the hard labor, anxiety, and self-sacrifice of the devoted physician in his endeavors to prevent or cure disease, or to mitigate the sufferings of mankind. The salient points in the second rule are: that the phy- sician treat his patients with attention, steadiness, and humanity; that he be indulgent to the caprices or mental imbecility of the sick; that delicacy and secrecy be strictly observed; and that the obligation of secrecy extends beyond the period of professional services. All the clauses of this second rule deserve close atten- tion, but more particularly the third which is of the great- est moment to the patient as well as to the physician. The injunctions of the first and second clauses are intended for beginners who, though they be steady, attentive, and humane in the treatment of their patients, may not have learned certain of the peculiarities of the sick and may, at times, display too much impatience at the whims and the unreasonable .demands of some invalids whom the older physicians characterize as querulous and distrustful, but recognize these traits as effects of the diseased condi- tion of, but not as inherent to, the individual whose natural disposition may be gentle and amiable. There- 162 THE PHYSICIAN AND HIS PATIENT fore, hyperesthetic invalids should not be held account- able for their frequent expressions of impatience or their extravagant actions for all of which the wise physician makes due allowance. The third clause of this rule is of paramount importance to the physician, to the patient, to the patient's family, to society in general, and to the state. Although para- phrased from the seventh sentence of the Hippocratic Oath, it omits a certain phrase of that seventh sentence which is so suggestive of the wisdom of forming the habit of being silent about the concerns of neighbors. The state- ment, in the American system of morals, that "the obli- gation of secrecy extends beyond the period of professional services," evidently does not include the idea conveyed in the Hippocratic Oath; namely: "Whatever in connexion with my professional practice, or not in connexion with it, 1 may see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret." This admirable moral maxim, with its necessary details, could not have been expressed more tersely and clearly. It surely suggests the cultivation of the habit of keeping a close mouth, a golden silence, regarding occurrences which, directly or remotely, may affect others. Excessive garrulity has too often been the cause of great mischief, of which sad ex- amples are not lacking. Therefore whatever the physi- cian sees or hears, at any time or place, in or out of his professional capacity, that should not be revealed, he is bound in honor, in conscience, to keep it secret from any 163 MORAL PHILOSOPHY OF MEDICINE person whomsoever. The strict observance of this clause, or rather of the seventh sentence of the Hippocratic Oath, is of importance to the physician because the merely incidental, incautious, mention of an occurrence even such as may seem but trifling, is likely to be magnified in char- acter, with verbal additions, from mouth to mouth, much to the injury of one, and often of more than one innocent person. It is important to the patient because he is naturally unwilling that his ails or affairs be made public. He therefore resents such a breach of faith on the part of any indiscreet attendant or physician; the consequence being loss of confidence in, and cessation of all relations with, a medical man or attendant who discloses secrets. It is important to the patient's family that his secrets be inviolate, even in minor circumstances, because of the exaggerations of scandal mongers. It is important to society at large because violations of professional secrets, and their immediate effects tend to lower the standard of morality. And it is of very much importance to the state as connected with the administration of justice. The client of a physician has every right to his professional services even though the physician ascertain, during his treatment, that the patient is a criminal, no matter of what sort or degree. In such a case, the physician is bound in conscience not to reveal the fact, or a single cir- cumstance connected with the crime, of which he may become cognisant during his attendance. When the phy- sician is summoned to give testimony in a court of justice, he is absolved from replying to any question which he is 164 THE PHYSICIAN AND HIS PATIENT not able to answer without compromising a client from whom he has obtained the information in his professional capacity. The law of the state of New York, in this par- ticular, is explicit, and is as follows: "A person duly authorised to practice physic or surgery shall not be allowed to disclose any information which he has acquired in attending a patient in his professional capacity, and which was necessary for him to act in that capacity." A similar statutory law exists in several other states. To the question-"what should be the conduct of the phy- sician as regards his visitations to patients, in point of length and frequency?'' The answer is that the first visit must necessarily be long in order to give sufficient time for diagnosis and for instructions, to the attendant or to the sufferer, as to the proper use of the remedies prescribed. But subsequent visits should not last longer than required to ascertain the condition of the patient and to give such directions as may be needed. After this, prolonged visits, as a general rule, are not conducive to the benefit of the patient. Short, frequent visits are absolutely necessary in cases of acute diseases. The third section of the first article of the first chapter of the National System of Medical Morals tells of the neces- sity of frequent visits to the sick, but condemns unneces- sary visits, as follows: "Frequent visits to the sick are in general requisite, since they enable the physician to arrive at a more perfect knowledge of the disease-to meet promptly every change 165 MORAL PHILOSOPHY OF MEDICINE which may occur, and also tend to preserve the confidence of the patient. But unnecessary visits are to be avoided as they give useless anxiety to the patient, tend to dimin- ish the authority of the physician, and render him liable to be suspected of interested motives." It is asked-"what constitutes frequent visits?" There are diseases which require the attention and observation of the physician two, three, or four times daily and per- haps once at night; whilst in other cases five or six visits each week would be regarded as too frequent. Beginners are apt to make too few visits to the sick, under the wrong impression that the patients or their relatives might attribute frequency in the visitations to self-interest. The conscientious physician makes as many or as few visits as the case requires. Of unnecessary visits Dr. Percival wrote, in the thir- teenth section of his second chapter: "Visits to the sick should not be unseasonably repeated; because, when too frequent, they tend to diminish the authority of the physician, to produce instability in his practice, and to give rise to such occasional indulgences as are subversive of all medical regimen." H'hat should be the line of conduct in regard to prognos- tications? The physician, after diagnosticating a disease, almost invariably, is at once asked, by the patient or by his friends, how long he will be ill or whether he will recover? Familiar as he is with the master's great book of prognos- tics, the wise medical adviser is ordinarily very cautious 166 THE PHYSICIAN AND HIS PATIENT in the expression of an opinion until he has completed his inquiries into the antecedent history of the patient, into the effect of previous treatment, if there has been any, and until he shall have carefully observed the general con- dition of the sufferer. This caution is proper even in a simple, promising case, some intercurrent affection or some unlooked-for serious complication may, at any mo- ment, be detected. He knows that too much optimism is as bad as extreme pessimism in any case, and wisely avoids alarming the patient by expressing hopelessness and avoids encouraging him when there is absolutely no hope of recovery. In foretelling the termination of a disease the true physician is so tactful as neither to over- encourage nor to discourage. He never promises a cure, nor does he brutally tell his patient that he is doomed to die at the date which he prophecies. It so often hap- pens that apparently moribund patients rally and recover, that the old saw-"while there is life there is hope''- should not be derided, for it is always consoling to rela- tives. Even in very malignant diseases, by good man- agement and assiduous care, pain is mitigated and life is often prolonged and made tolerable for months and even for years. Hence it is that the experienced physician is always guarded in prognostics. In the third section of his second chapter, Doctor Per- cival gives the following rules of conduct respecting prog- nostications: "A physician should not be forward to make gloomy prognostications; because they savour of empiricism, by 167 MORAL PHILOSOPHY OF MEDICINE magnifying the importance of his services in the treatment or cure of the disease. But he should not fail, on proper occasions, to give, to the friends of the patient, timely notice of danger, when it really occurs, and even to the patient himself, if absolutely necessary. This office, how- ever, is so peculiarly alarming, when executed by him, that it ought to be declined, whenever it can be assigned to any other person of sufficient judgment and delicacy. For the physician should be the minister of hope and comfort to the sick; that by such cordials to the drooping spirit, he may smooth the bed of death; revive expiring life; and counteract the depressing influence of those maladies which rob the philosopher of fortitude and the Christian of consolation." The framers of the National System adopted this ad- mirable section almost word for word, and added thereto the following: ''The life of a sick person can be shortened not only by the acts, but also by the words or the manner of the phy- sician. It is, therefore, a sacred duty to guard himself carefully in this respect, and to avoid all things which have a tendency to discourage the patient and to depress his spirits." Gloomy pognostications made with intent to magnify medical skill are worse than dishonorable, and worthy only of those charlatans who preten^ to be able to ward off any disease or to substitute a mild affection for a grave disorder. Those cunning, crafty, medical vultures incessantly prey upon the credulity of innocents w'hom 168 THE PHYSICIAN AND HIS PATIENT they encourage in the belief that all diseases are inter- changeable through marvelous methods known only to them. It is a lamentable fact that there are some physicians of the highest integrity who are ordinarily gloomy prog- nosticians and who, on entering the sick room, too often manifest groundless apprehension more, however, by look and manner than by words. Doctor Flint contrasts the pessimistic and the optimis- tic physicians in his wonted happy style as follows: "Un- due solemnity, anxiety, and apprehension in the looks, manner, or words of a medical attendant on the sick, are extremely unfortunate-they discourage patients, whereas, on the other hand, a cheerful mien, calmness of deport- ment, and verbal assurances, sometimes accomplish more than drugs." One or two instances of hasty prognosis may not be without interest. A well-known citizen consulted a physician who told him that the trouble of which he complained would prove fatal in the course of three or four months. The patient was alive and well fifteen years after that hasty declara- tion, whilst the Doctor had gone to sleep with his fathers a few years after this condemnation of the anxious suf- ferer. Another patient affected with some cardiac dis- turbance, when told by his physician that he had but one chance of life in a thousand and that the end would prob- ably come very soon, said smilingly: Well, 1 shall take that one chance; and he lived more than thirty years 169 MORAL PHILOSOPHY OF MEDICINE thereafter; dying of another disease when upward of eighty years of age. Many other examples might be cited to show the unwisdom of gloomy prognostications delivered hastily and directly to patients. Such conduct cannot fail to throw discredit upon the profession of medicine and to give occasion for the decrial of regular physicians by charlatans. Should the physician continue attendance on a case which he regards as incurable? There is no other reason for the discontinuance of such attendance than the expressed wish of the patient or friends to dispense with medical services. Otherwise it is the duty of the physician to continue to minister to the comfort of the patient to the very last moment of his life; using proper discretion as to the frequency of his visits. From motives of delicacy, young physicians are too ready to cease visiting patients whom they believe to be incur- able, or in whose recovery they have lost all hope; think- ing it unfair to demand fees which they imagine might not be honestly earned should they continue their visitations. 1 hose holding such opinions unquestionably do their patients and themselves great injustice. The fifth section of the first article in the National Sys- tem of Medical Morals, is the best answer to this question. It states briefly the reasons why the physician should not discontinue attendance on cases whose recovery is hope- less, and is as follows: "A physician ought not to abandon a patient because the case is deemed incurable; for his attendance may 170 THE PHYSICIAN AND HIS PATIENT continue to be highly useful to the patient and comforting to the relatives around him, even in the last period of a fatal malady, by alleviating pain and other symptoms, and by soothing mental anguish. To decline attendance under such circumstances, would be sacrificing to fanciful delicacy and mistaken liberality, that moral duty which is independent of, and superior to, all pecuniary considera- tion." Doctor Percival quotes Sir William Temple as asserting that "an honest physician is excused from leaving his patient when he finds the disease growing desperate, and can, by his attendance, expect only to receive his fees, without any hope or appearance of deserving them." " But this allegation," says Percival, "is not well founded; for, the offices of a physician may continue to be highly useful to the patient, and comforting to the relatives around him, even in the last period of a fatal malady; by obviating despair, by alleviating pain; and by soothing mental anguish. To decline attendance, under such cir- cumstances, would be sacrificing, to fanciful delicacy and mistaken liberality, that moral duty which is independent of, and far superior to, all pecuniary appreciation." When a physician has undertaken the management of a serious or difficult case, is it not wise for him to call on another in consultation? Yes. And he should be careful to select a loyal con- sultant, for it is his right to make the selection. The attending physician alone is competent to determine the kind of advice and adviser most likely to be of benefit to 171 MORAL PHILOSOPHY OF MEDICINE the patient. If, however, the patient or family should insist upon calling in the consultation a physician who is so objectionable that, in the opinion of this attending physician, the patient would be injured rather than benefitted in consequence, it is his privilege and duty to decline further connection with the case and gracefully retire. But, it is very seldom that he is forced to take such a course, as loyal patients generally follow the ad- vice of their physician as well in grave as in simple cases. In olden times consultations of physicians were too often the occasions of sad disputes and even the most scandalous conduct at the very bedside of the sick, over theoretic questions pertinent or not to the case, but always to the detriment of the patient. The frequency of such disgraceful encounters served to bring the pro- fession into ridicule and disrepute. From such conten- tions probably arose the ironical saying-"who shall de- cide when Doctors disagree." The satirists soon took advantage of these brawls to picture their actors in the most ludicrous situations. Witness Le Sage's account of the meeting of Gil Blas and Doctor Cuchillo at the sick- bed of an unfortunate victim who, weak as he was and almost ready to give up the ghost, had to make selection as to which of the two militants should end his misery, when they had each the other by the hair or were shower- ing reciprocal blows, all because of disagreement on phlebotomy and the hydrotherapy of the great Doctor Sangrado. It is not unlikely, because of occasional bed- side squabbles, even in his time, that Doctor Percival, 172 THE PHYSICIAN AND HIS PATIENT who was a strong advocate of the promotion of consulta- tions, wrote the seventh article of his second chapter, in which he enjoins peace and good will, as follows: "Consultations should be promoted, in difficult or pro- tracted cases, as they give rise to confidence, energy, and more enlarged views in practice. On such occasions no rivalship or jealousy should be indulged; candor, probity, and all due respect should be exercised toward the physi- cian or surgeon first engaged; and as he may be presumed to be best acquainted with the patient and with his family, he should deliver all the medical directions agreed upon, though he may not have precedency in seniority or rank. It should be the province, however, of the senior physician, first to propose the necessary questions to the sick, but without excluding his associate from the privilege of mak- ing farther inquiries to satisfy himself, or to elucidate the case." In protracted cases of illness, the attending physician is, of course, the best judge of the necessity for a consulta- tion, although he may make no objection thereto when proposed by the chief of the anxious family who should be warned against those overzealous meddlesome friends who, knowing nothing of the case, clamor even for a change of physicians and are too frequently successful in effecting such change, often to the detriment of the suf- ferer. When, too late, the patient or family realises the unwisdom of the determination to employ a stranger unfit in every respect to minister to the invalid. What is the duty of the physician who has, under his care, 173 MORAL PHILOSOPHY OF MEDICINE a patient whose mental condition, owing to bad habits, re- quires something more than medicines? In such a case it is the duty of the physician to exert all the moral influence he possesses over the invalid to induce him to amend his injurious ways which so greatly interfere with the treatment of the present illness and which would sorely complicate other forms of sickness. The seventh section of the first article of the first chapter of the National System, taken almost verbatim from Dr. Percival's work, indicates very clearly the manner of pro- ceeding in such cases, as follows: "The opportunity which a physician not unfrequently enjoys of promoting and strengthening the good resolutions of his patients suffering under the consequences of vicious conduct, ought never to be neglected. His counsels, or even remonstrances, will give satisfaction, not offense, if they be proffered with politeness, and evince a genuine love of virtue, accompanied by a sincere interest in the welfare of the person to whom they are addressed." The question relating to the implied or to a special covenant of physician or surgeon and patient will be the better answered in the following abstract of an article, on the "surgeon and patient," contained in Smith's " Doctor in Medicine": The agreement may be implied or expressed in terms. In either case the surgeon is responsible for the fulfillment of his part of the contract. The implied contract grows out of his offering his services to the public as a qualified practiser of his art; and in all suits for alleged mal-prac- 174 THE PHYSICIAN AND HIS PATIENT tice, the courts have uniformly held that the practiser is bound to bring to his case the ordinary degree of skill in his profession. In legal phrase, the implied contract of a physician or surgeon is not to cure, or to restore a part to its natural perfectness, but to treat his case with diligence and skill. His contract, as implied in law, is that: 1. He possesses the reasonable degree of learning, skill, and experience, ordinary to other members of the profes- sion; 2. That he will use reasonable and ordinary care and diligence in the treatment of the case committed to him; 3. That he will use his best judgment in all cases of doubt as to the best course of treatment If the physician or surgeon make a special contract with his patient, he is held strictly by its terms. SUMMARY Since the National System of laws for the government of physicians and of the people in their relations to phy- sicians tells them what they shall and shall not do, it may be well, for the benefit of all concerned, to summarise these laws in brief sentences; beginning with what the physi- cian shall and shall not do for the good of his patients. i. Be ever ready to obey the calls of the sick. 2. Be imbued with the high character of your mission. 3. Bear in mind that the ease, health, and lives of your patients depend on your skill, attention, and fidelity. 4. Forget not that there is no tribunal other than your 175 MORAL PHILOSOPHY OF MEDICINE own conscience to adjudge penalties for carelessness or neglect. 5. Unite tenderness with firmness in your deportment and so inspire your clients with respect, confidence, and gratitude. 6. Treat all your patients with attention, steadiness and humanity. 7. Be indulgent to the caprices or mental foibles of the sick. 8. Bear constantly in mind that delicacy and secrecy shall be strictly observed, and that secrecy extends beyond the period of professional services. 9. Make to the sick as many visits as are absolutely required, but no unnecessary visits. 10. Do not make gloomy prognostications within hear- ing of the sick. 11. Do not abandon a sufferer whose cure is beyond hope, but continue your ministrations to the last. 12. Be careful, when a consultation becomes necessary, to select a competent and loyal consultant. 13. Do not omit to exert your influence toward his reformation when a patient's habits are injurious to him in his sickness or afterward. 176 XI THE PATIENT AND HIS PHYSICIAN Reciprocal obligations of patients and their physicians-The patient's selection of a physician-Prompt obedience to the directions of the physician either for the prevention or cure of disease-Importance of seeking advice at the earliest manifestation of any sickness-Irrelevant and wearisome details, in the statement of his case, to be avoided by the patient-Strict observance of the rules prescribed during convalescence-No friendly visits from physicians who are not in attendance-The patient to be always in readiness to receive his physician. The questions to be treated in this conference are of even greater import to the patient than to the physician who should spare no pains to make them known to all his clients in order that they may clearly understand the true nature of their relations and obligations to physicians whose ministrations they may invoke. It is the lack of knowledge of the characters of these relations and obliga- tions that has too often led to grave misunderstandings, and to many evil consequences. For this want of knowl- edge of the laws governing the conduct of patients, medi- cal men have been almost wholly answerable. It is therefore incumbent upon every individual physician to impart the needed information to all his patients, and upon the profession as a whole to enlighten the public on questions of medical morals the knowledge of which is essential to the well being of all communities. 177 MORAL PHILOSOPHY OF MEDICINE The young inquirer into the principles of conduct of medical men very naturally propounds the following: "Since physicians are governed and bound by fixed rules to perform all the arduous duties required in the care of the sick, ought not their patients be equally governed and hound by rules that are essential to the preservation of health and to the cure of disease?'' The chief obligations of the patient to his physician, besides obedience to his directions, are loyalty, respect, gratitude, and due acknowledgment of the faithful services rendered. All patients are bound in obedience to their physicians, or take the consequences of disobedience, and are bound morally and legally to make due acknowledg- ment of services rendered. The strictest obedience of the sick was exacted from the very beginning of the healing art. The physician gave his instructions to the patient who was to be treated solely on condition of implicit pli- ance with these instructions; such was, and is still, the covenant. The second sentence of the first Hippocratic aphorism: "The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate," shows that, even in early times, the rules governing the obligations of patients must emanate from their physicians who alone can make such rules. Without an understanding that the patient shall obey directions, the medical adviser is rarely willing to undertake the management of a sick person. The principle of reciprocity between physician and 178 THE PATIENT AND HIS PHYSICIAN patient necessarily involves some proper return always, however, coupled with gratitude for a service rendered. The physician being bound to use his best abilities in ministering to the ails of his patients; these are equally bound to him in obedience, respect, gratitude, and other ways of manifesting their obligations. Therefore it is incumbent upon the physician to make known to all his patients the exact nature of his duties to them and of their obligations to him in order that they may clearly understand the purport of the contract. The National System of Medical Morals was instituted for the protection and information, not only of physicians but of patients and of the public, and to impress upon all the fact that their obligations must necessarily be recipro- cal. One of the objects of the National Medical Associa- tion, distinctly stated in its original plan of organization, is "the enlightenment and direction of public opinion in regard to the duties, responsibilities, and requirements of medical men." This object can be effected only by mak- ing the public acquainted with the laws of the associated members of the profession of medicine. That part of the national system which points out the reciprocal obliga- tions of clients and physicians is so clear and just that no intelligent layman who reads it will question its propriety and absolute necessity, and all heedful readers will surely approve of the other parts which relate to the public and the state. Even a cursory examination of the letter of the second article of the first chapter of the National System will not 179 MORAL PHILOSOPHY OF MEDICINE be without interest and instruction to the beginner. The heading of this article is: "Obligations of patients to their physicians," and the first section is as follows: "The members of the medical profession, upon whom is enjoined the performance of so many important and arduous duties toward the community, and who are re- quired to make so many sacrifices of comfort, ease and health, for the welfare of those who avail themselves of their services, certainly have a right to expect and require that their patients should entertain a just sense of the duties which they owe to their medical attendants." It is almost needless to say more than that the physician in full practice leads a truly self-sacrificing life, with little rest, few social enjoyments, and less recreation, and that his hardships and responsibilities cannot be known outside his professional circle for, his heavy mental burden is gen- erally concealed by calmness and cheerfulness of manner. The situation of the physician at the bed-side of the dying is always extremely painful to him, and there, his calmness and self-control are too frequently misinterpreted byonlookers for indifference and induration. His respon- sibility, anxiety, unremitting laborious attention, so much greater in a case which ends fatally than in a grave case that recovers, and his persistent efforts to mitigate suffer- ing and prolong life, entitled, as they are, to the kindest recognition, evoke only small thanks in too many in- stances. The prolongation of life for a single day or'even for a few hours is often of the greatest importance to the patient and to the family who implore the physician to 180 THE PATIENT AND HIS PHYSICIAN try his best skill toward the accomplishment of this ob- ject. One of the great triumphs of Sir Astley Cooper was when he tied the abdominal aorta to give a man, dying from the effects of a diffuse aneurism, time to make his will. In this case the patient and his heirs showed the highest appreciation of the service. The second section, relating to the selection of a medi- cal adviser, is of prime importance to the patient, and is brief and to the point: "The first duty of a patient is to select as his medical adviser one who has received a regular professional edu- cation. In no trade or occupation do mankind rely on the skill of an untaught artist; and in medicine, confessedly the most difficult and intricate of the sciences, the world ought not to suppose that knowledge is intuitive." The patient having made his selection; the physician, if he accept-for he may decline-attendance, is bound to use his best skill and endeavor to relieve the ails of his client, and, on his part, the client is under strict obliga- tion to obey the instructions of the physician; otherwise this client alone is responsible for the consequences of the disobedience. When instructions are disregarded by the attendant, the physician should at once cause the dis- missal of the refractory attendant, and in case of obstinate disobedience of the patient, the physician is justified to retire from the case; implicit obedience being and having been always exacted as a condition of attendance by all prudent medical men. The second sentence of the first Hippocratic aphorism is the earliest recorded warrant for. 181 MORAL PHILOSOPHY OF MEDICINE the exaction of cooperation, in sickness, not only of the patient but of "attendants and externals." On the subject of "Physician, Patient and Physic," Robert Burton, whose quaint language of three centuries ago is always so interesting to modern scholars, says: "Next therefore to God, in all our extremities we must seek to, and rely upon, the physician, who is manus Dei, saith Hierophilus, and to whom he hath given knowledge, that he might be glorified in his wondrous works It is not therefore to be doubted that, if we seek a physi- cian as we ought, we may be eased of our infirmities, such a one 1 mean as is sufficient, and worthily so called; for there be many mountebanks, quacksalvers, empiricks, in every street almost, and in every village, that take upon them this name, make this noble and profitable art to be evil spoken of, and contemned by reason of these base and illiterate artificers; but such a physician 1 speak of as is approved, learned, skilful, honest" .... con- cerning the patient, he says: "When these precedent cautions are accurately kept, and that we have now got a skilful, an honest physician to our mind, if his patient will not be conformable, and content to be ruled by him, all his endeavors will come to no good end. Many things are necessarily to be observed and continued on the patient's behalf. First that he be not too niggardly miserable in his purse, or think it too much he bestows upon himself, and to save charges endanger his health. . . . Another thing is that he do not out of bashfulness conceal his grief; if aught trouble his mind let him freely disclose 182 THE PATIENT AND HIS PHYSICIAN it A third thing to be required in a patient is confidence, to be of good cheer, and have hope that his physician can help him " In connection with the patient's selection of a medical adviser, a young physician asked: "How mud has man- nerism to do with the popularity of a physician?'' Artificial mannerism is always in bad taste. The awk- ward man betrays himself whenever he strives to assume ways which are not natural to him; and if the polished, refined man were to "put on" eccentric airs he would sacrifice his dignity and be in danger of incurring ridicule. In many cases the naturally brusque man is endowed with such excellent moral and professional qualities as counter- balance his abrupt ways which do not interfere with pleasant relations with his clients who like him despite external appearances. With all his brusqueness and im- patient manner, Abernethy's great genius imposed respect, while his warm heart and noble deeds made him generally beloved. The tactful physician does not say to any woman-apply a compress as large, but as small, as your hand. He speaks of some object as smooth as the baby's cheeks, as rosy as its pretty lips. This is always pleasing to the fond mother; and no sensible man would make such comparisons unless they were pertinent and illustra- tive. The true physician never compromises his dignity by observing such amenities of social life in the sick-room with due discretion in manner and speech. Natural man- nerism is not pleasing and indeed it is very objectionable to many persons, but artificial mannerism as well as 183 MORAL PHILOSOPHY OF MEDICINE obsequiousness is intolerable and repulsive to all; while a keen sense of the fitness of things, and the ability to seize time, place, and circumstance for the agreeable expression of particular thoughts, are precious gifts to the physician. It is said of the venerable Doctor John Redman, of Philadelphia, who was still alive in the beginning of the nineteenth century, that "in a sick room he possessed virtues and talents of a peculiar kind. He suspended pain by his soothing manner, or chased it away by his conver- sation which was occasionally facetious and full of anec- dotes, or serious and interesting, according to the nature of his patients' diseases or the state of their minds." Entire freedom from austerity, exquisite tact with in- bred elegant, dignified manners, and a naturally good, cheerful disposition caused the great popularity of Doctor Richard Warren and Doctor Matthew Baillie in consulta- tion with physicians and in their relations with patients. They were princes among fashionable people and charm- ing men, honored in all walks of life. In this country there is no lack of such physicians. But only a few of those who have passed away will be named. Foremost among them was the learned Doctor John W. Francis whose charming personal characteristics, great medical and gen- eral erudition, phenomenal memory, vast historic lore, and bubbling good nature, endeared him not only to the profession but to the whole community who will long remember his wise sayings and his marvelous elocution. Then arose to great prominence Doctor Alonzo Clark 184 THE PATIENT AND HIS PHYSICIAN whose simple, gentle manners, dignified mien, majestic stature, massive head, intellectual expression of counte- nance, great learning, admirable diagnostic skill, and rare prognostic wisdom, always inspired the physician with reverence in and out of the consulting room, the patient with confidence, and the family with hope-he was indeed an exemplarily good man and great physician, almost as skilful as he was honest. One of his eminent contempo- raries was Doctor John T. Metcalfe, the optimistic, clever family physician and elegant man, who retained a large and lucrative fashionable clientage for nearly half a cen- tury; and another was the learned, loved, cheering Doctor Austin Flint whose presence in the sick-room was always hailed by all as a benediction, who was held in the greatest reverence by his grateful hospital patients, by his stu- dents, by his appreciative colleagues, and by the many physicians whom he so much aided in consultation. Spurious healers, pretenders, and would-be fashionable medicasters disappear from the medical horizon as soon as their fraudulent schemes are discovered; whilst true men last and thrive by reason of professional ability, simple manners, pleasing cheerfulness, good taste in let- ters and art, consummate tact, absolute self-command, and masterly discretion. The third and fourth sections of this second article are so full and explicit as to leave no doubt in the mind of the reader regarding their utility and importance to the pa- tient, and therefore require no explanation or elaboration. ''Patients should prefer a physician whose habits of life 185 MORAL PHILOSOPHY OF MEDICINE are regular, and who is not devoted to company, pleasure, or any pursuit incompatible with his professional obliga- tions. A patient should also confide the care of himself and family, as much as possible, to one physician; for a medical man who has become acquainted with the pecu- liarities of constitution, habitsand predispositions of those he attends is more likely to be successful in his treatment than one who does not possess that knowledge. A patient who has thus selected his physician should always apply for advice in what may appear to him trivial cases, for the most fatal results often supervene on the slightest acci- dents. It is of still more importance that he should apply for assistance in the forming stage of violent diseases; it is to a neglect of this precept that medicine owes much of the uncertainty and imperfection with which it has been reproached." "Patients should jaithjully and unreservedly communicate to their physician the supposed cause of their disease. This is more important, as many diseases of a mental origin simulate those depending on external causes and yet are only to be cured by ministering to the mind dis- eased. A patient should never be afraid of thus making his physician his friend and adviser; he should always bear in mind that a medical man is under the strongest obliga- tions of secrecy. Even the female sex should never allow feelings of shame or delicacy to prevent their disclosing the seat, symptoms, and causes of complaints peculiar to them. However commendable a modest reserve may be in the common occurrences of life, its strict observance in 186 THE PATIENT AND HIS PHYSICIAN medicine is often attended with the most serious conse- quences, and a patient may sink under a painful, and loathsome disease, which might have been readily pre- vented had timely intimation been given to the physician." The fifth section interests not only the patient but the physician who should take good care to enforce its wise provisions. "A patient should never weary his physician with a tedious detail of events or matters not appertaining to his disease. Even as relates to his actual symptoms, he will convey much more real information by giving clear answers to interrogatories, than by the most minute account of his own framing. Neither should he obtrude upon his physician the details of his business nor the history of his family concerns." The sixth section of this article of the first chapter of the American System relates not only to the obligation of obedience on the part of the patient, but points out the dangers of the disregard of instructions and of the accept- ance of extraneous advice and of the use of medicines recommended by unqualified persons. It is as follows: "The obedience of a patient to the prescriptions of his physician should be prompt and implicit. He should never permit his own crude opinions as to their fitness to .influence his attention to them. A failure in one particular may render an otherwise judicious treatment dangerous, and even fatal. This remark is equally applicable to diet, drink, and exercise. As patients become convalescent they are very apt to suppose that the rules prescribed for 187 MORAL PHILOSOPHY OF MEDICINE them may be disregarded, and the consequence, but too often, is a relapse. Patients should never allow themselves to be persuaded to take any medicine whatever that may be recommended to them by the self-constituted doctors and doctresses who are so frequently met with, and who pretend to possess infallible remedies for the cure of every disease. However simple some of their prescriptions may appear to be, it often happens that they are productive of much mischief, and in all cases they are injurious, by contravening the plan of treatment adopted by the phy- sician." The admonitions of the seventh section are also very wholesome to patients: ''A patient should, if possible, avoid even the friendly visits of a physician who is not attending him-and when he does receive them, he should never converse on the subject of his disease, as an observation may be made, without any intention of interference, which may destroy his confidence in the course he is pursuing, and induce him to neglect the directions prescribed to him. A patient should never send for a consulting physician without the express consent of his own medical attendant. It is of great importance that physicians should act in concert; for although their modes of treatment may be attended with equal success when applied singly, yet conjointly they are very likely to be productive of disastrous results." A very good rule, generally adhered to by honorable medical men, is never to visit a sick friend who is under the care of another physician, unless summoned in con- 188 THE PATIENT AND HIS PHYSICIAN sultation, and no loyal physician ever thinks of intruding himself into a consultation, nor does he obey any call for a consultation that is not made by, or with the consent of, the physician in charge. The eighth section is a fair and equitable demand for justice to the physician, who is surely entitled to the opportunity of exculpation when a charge or charges are made which lead to his dismissal. "When a patient wishes to dismiss his physician, jus- tice and common courtesy require that he should declare his reasons for so doing." A physician may be dismissed on account, as may have been alleged, of his having, in some way forfeited the confidence of the patient or family; and motives of deli- cacy may deter either from revealing the precise cause of this loss of confidence which may have been due to the evil influence of some tale-bearing person, or to damaging reports-generally unfounded-made covertly by an intriguing, dishonorable rival for the purpose of supplant- ing him.. Unfortunately, however, he does not always ascertain the truth until it is too late. His wounded pride deterring him from ever resuming his professional relations with a family that gives credence to false charges, even though the patient and family had discovered his innocence and reconsidered their hasty determination. Therefore it is always due to the physician that the reason for dissatisfaction, and for the desire to dismiss him, be promptly given by the patient or a member of the family, in order that he may have an ample opportunity to dis- 189 MORAL PHILOSOPHY OF MEDICINE prove any allegations against his character or professional competency. On this subject, Doctor Flint, who thought the mere statement of loss of confidence to be sufficient in any case, said: "Patients who have lost confidence in their physicians should request discontinuance of their services. So essen- tial is full confidence in the treatment of cases of disease that it is a false delicacy to conceal the want of it. It is best for both the patient and the physician that there be a change The loss of confidence is in itself a sufficient reason, no matter how unreasonable A high-minded physician cannot wish to continue in charge if he cannot have the confidence of the patient. He should take the initiative in the relinquishment of the case whenever he is satisfied that confidence is lost.'' It must here be said that the physician too, should have confidence in his patient's loyalty, obedience and readiness to follow directions, otherwise he would be justified to cease attendance. The wisdom and justice of the provisions of this, the ninth section are evident to all. "Patients should always, when practicable, send for their physician in the morning, before his usual hour for going out; for by being early aware of the visits he has to pay during the day, the physician is able to apportion his time in such a manner as to prevent an interference of engagements. Patients should also avoid calling on their medical adviser unnecessarily during the hours devoted 190 THE PATIENT AND HIS PHYSICIAN to meals or sleep. They should always be in readiness to receive the visits of their physician, as the detention of a few minutes is often of serious inconvenience to him." These injunctions will be fully appreciated by all who have a proper regard for their medical adviser and are mindful of his comfort, and anxious for the maintenance of the integrity of his physical condition so necessary to the efficient exercise of his laborious duties. In reference to the last sentence of this section enjoining readiness to receive the visits of the physician, the special attention of clients should be called to the fact that detention in the antechamber even for a few minutes is not only a vexa- tious loss of time to the medical attendant, but an injus- tice to another patient who, perhaps in great suffering, may be anxiously awaiting the tardy arrival of the physician. The tenth is the last section of this article. "A patient should, after his recovery, entertain a just and enduring sense of the value of the services rendered him by his phy- sician; for these are of such a character that no mere pecuniary acknowledgment can repay or cancel them." It is an appropriate reminder of that last-which should be lasting-obligation, gratitude, ever dearer to the phy- sician than all prior acknowledgments. Grateful recogni- tion of faithful services, not being the most common of human traits, when warmly expressed by the few, is always a sweet compensation for the want of appreciation of the many. 191 MORAL PHILOSOPHY OF MEDICINE SUMMARY What the patient shall do and what he shall not do for his own good. i. Bear in mind that your first duty to yourself and family is to select a physician who is known to have received a proper medical education and whose habits are good. 2. Follow implicitly the advice of your physician toward the prevention of sickness. 3. Obey promptly the directions of your physician in case of sickness, and thus help to hasten your recovery. 4. Always apply for the physician's advice at the earliest manifestation of sickness. 5. Do not hesitate to communicate, to your physician, without reservation, the supposed cause of your sickness. 6. Do not fear to make your physician a friend and adviser, for he is bound by oath to keep secret all com- munications you make to him. 7. Do not weary your physician with tedious or irrele- vant details, or with things which do not pertain to your sickness. 8. Do not defer carrying out the prescriptions and direc- tions of your physician. 9. Do not disregard any of the rules directed to be observed during convalescence. 10. Do not be persuaded to take any medicine what- ever that is not prescribed by your physician. 192 THE PATIENT AND HIS PHYSICIAN ii. Do not receive even friendly visits from a physician who is not attending you professionally. 12. Do not speak of your sickness to a strange physi- cian whom you may be obliged to receive on some par- ticular business not connected with your sickness. 13. Do not, except in an emergency, send for your physician during his hours of refection or rest. 14. Always be in readiness to receive the visits of your physician. 15. Do not keep him waiting in the antechamber, since such a detention would perhaps be injurious to another patient who, in great suffering, might be anxiously await- ing the tardy arrival of the physician. Patients endowed with good sense who have a just appreciation of their physician do not hesitate to obey these wise injunctions 193 XII THE PHYSICIAN, PROFESSION, AND PUBLIC Obligations of physicians to the profession and to each other- Maintenance of the dignity and honor of the profession- Extension of the bounds of its usefulness-Contributions of lore to enrich the science of medicine-Criterion of the true physician-Temperance in all things-The physician's medi- cal adviser-Vicarious offices-Duties in consultations and in cases of interference-Differences between physicians- Pecuniary acknowledgment and compensation-Relations of the profession and the public. Since the postulant, on entering the medical profession becomes entitled to all its privileges and immunities, he is under obligation to exert his best abilities to maintain its dignity and honor; to exalt its standing; to extend the bounds of its usefulness; to contribute such material as will enrich the science; to entertain a due respect for his seniors who, by their labors, have brought it to the high position it occupies; and to obey all laws instituted for the government of its members. Such, in substance, are some of the injunctions of the National System (in the first article of its second chapter), as relate to duties for the support of professional character. Nothing need be added to these noble precepts which have done so much to inspire all true men of the profession with the right spirit of the grand corps of faithful laborers 194 PHYSICIAN, PROFESSION, AND PUBLIC in the broad field of the science whose chief object is to promote the well-being of all mankind. Honesty, kindness, purity of character, dignity of bear- ing, temperance in all things, correct moral principles, tact, discretion, industry, skill, and general and profes- sional acquirements of a high order, help to make up the criterion of the true physician, as so clearly and admirably detailed in the third section of the first article of the second chapter of the National System, as follows: "There is no profession from the members of which greater purity of character and a higher standard of moral excellence are required, than the medical; and to attain such eminence is a duty every physician owes alike to his profession and to his patients. It is due to the latter, as without it he cannot command their respect and confi- dence, and to both, because no scientific attainments can compensate for the want of moral principles. It is also incumbent on the faculty to be temperate in all things, for the practice of physic requires the unremitting exer- cise of a clear and vigorous understanding; and in emer- gencies, for which no professional man should be unpre- pared, a steady hand, an acute eye and an unclouded head may be essential to the well-being, and even to the life, of a fellow creature." The first and second sentences of this third section are ably commented by Doctor Stephen Smith in his "Doctor in Medicine," substantially as follows: "It does not fol- low because a man has acquired large stores of knowledge that he may not, at the same time, be a low and vulgar 195 MORAL PHILOSOPHY OF MEDICINE boor, whose self-conceit or selfishness leads him to trample alike upon the rights and the feelings of his professional brethren, in his insensate haste to become rich, or to gain the bubble reputation. These things are of too frequent occurrence not to have been noticed by all, and it is not difficult in any community to point out some physicians who, great enough in intellectuality, are yet moral idiots in respect to the dignity and the honor of the profession they follow. Such men, whatever their talents, their wealth, or their factitious distinctions, are still living in virtual outlawry to the canons of medical morals, nor can the ephemeral praises of an indiscriminate press indemnify them for the lost sympathy and respect of their fellows. Pitiable indeed is the condition of that man who is shunned by his peers, whose name provokes only contempt, and who is dismissed from their thoughts as one fallen from the high estate of a Christian gentleman and an honorable man." To these wise words it need only be added that the phy- sician who barters his shadow, his very soul, for Fortuna- tus' purse will learn too late that he cannot reclaim his honor from the "gray man;" and in his hopelessness and desperation, shunned, though pitied, by all honest men, he will exclaim-" J usto judicio Dei judicatus sum; justo judicio Dei condemnatus sum!" Rabelais, the physician, who could often be serious and expound sound moral principles, said, in one of Gargan- tua's letters to his son, studying in Paris, ''Science sans conscience nest que ruine de Tame." 196 PHYSICIAN, PROFESSION, AND PUBLIC That it is derogatory to professional dignity for physi- cians to resort to public advertisements of any sort, there can be no doubt, for they then would place themselves on the level of charlatans and merit general reprobation; and that it is equally derogatory to professional character to receive or demand commissions of whatever kind, or hold a patent for any instrument or medicine, or to give countenance to such, the profession has absolutely declared. The following questions were asked by a young physician: "Should a physician demand any fee for services to a member of the immediate family of another physician?'' "Should a physician prescribe for himself or for his im- mediate family?" These questions are fully answered in the second chap- ter of the National System, through the second article. "Professional services of physicians to each other," whose provisions are that all practisers of medicine, their wives, and "their children when under parental care, are entitled to the gratuitous services of any one or more of the faculty, residing near them, whose assistance may be desired. A physician afflicted with disease is usually an incompetent judge of his own case; and the natural anxiety and solicitude which he has at the sickness of a wife, a child, or any one who, by ties of consanguinity, is ren- dered peculiarly dear to him, tend to obscure his judg- ment and produce timidity and irresolution in his practice. Under such circumstances medical men are peculiarly 197 MORAL PHILOSOPHY OF MEDICINE dependent upon each other, and kind offices and profes- sional aid should always be cheerfully and gratuitously afforded. Visits ought not, however, to be obtruded officiously; as such unasked civility may give rise to em- barrassment, or interfere with that choice on which con- fidence depends. But if a distant member of the faculty whose circumstances are affluent, requests attendance and an honorarium be offered, it should not be declined; for no pecuniary obligation ought to be imposed which the party receiving it would not wish to incur." This article makes it very clear that the physician should not attempt to heal himself, despite the ancient proverb. He should have his well-selected medical ad- viser, as the lawyer has his legal adviser, and as the priest has his spiritual adviser. The third article is an excellent guide to all physicians in their friendly relations and in their mutual aid. It points out concisely and clearly what should be the conduct of the honorable physician when acting for an absent col- league, and also the obligations of both on the return of the absentee. This article, bearing the title "Of the duties of physicians as respects vicarious offices," is as follows: "The affairs of life, the pursuit of health, and the vari- ous accidents and contingencies to which a medical man is peculiarly exposed, sometimes require-him temporarily to withdraw from his duties to his patients, and to request some of his professional brethren to officiate for him. Compliance with this request is an act of courtesy which 198 PHYSICIAN, PROFESSION, AND PUBLIC should always be performed with the utmost considera- tion for the interest and character of the family physician, and, when exercised for a short period, all the pecuniary obligations for such service should be awarded to him. But if a member of the profession neglect his business in quest of pleasure and amusement, he cannot be considered as entitled to the advantages of the frequent and long- continued exercise of this fraternal courtesy without awarding, to the physician who officiates, the fees arising from the discharge of his professional duties." "In obstetrical and important surgical cases, which give rise to unusual fatigue, anxiety, and responsibility it is just that the fees accruing therefrom should be awarded to the physician who officiates." The selection of a colleague to act vicariously should be made with care because there are dishonorable physi- cians who take such an opportunity to prejudice unsus- pecting persons, against their absent physician, by in- nuendoes and other covert means. But those patients who are aware of the nature of this article soon discover the treachery of the false friend of their physician, treat the delinquent accordingly, and gladly welcome the absentee. The honest physician, even if preferred to his absent friend, invariably declines to continue his attendance after the arrival of the family physician. The fourth article, which relates to the duties of physi- cians in regard to consultations, is worthy of the closest study of all physicians. Its able framers sought, in simple but exact and elegant language, to inculcate broad, liberal, 199 MORAL PHILOSOPHY OF MEDICINE and humane principles; to provide for all contingencies; and to include the most explicit rules of conduct, together with valuable ceremonial regulations which should never be dissociated from the other regulations. All these be- coming rules of etiquette closely follow or are even incor- porated, as they should be, with special rules of conduct, for, widely separated therefrom they would be of very little use. The beginner wants to know the object and nature of a consultation of physicians in any case of disease. Such a consultation has for its object the good of the patient whose physical or mental condition demands it. The nature of its conduct is as follows: Two or more than two physicians meet in the antechamber for a preliminary conference, then go to the bed-side of the sufferer, examine him with care to ascertain his general and special state of body and mind, and then retire to a private place for mature deliberation with a view of making a decision as to diagnosis, therapeusis, and prognosis. Therefore a legitimate consultation can occur only among physicians who believe in one indivisible science and art of medicine and who consequently speak the same medical lan- guage; otherwise such a meeting could not result in the good of the patient, which is the sole object of such a consultation. The main features of the excellent rules of conduct in physicians' consultations prescribed by the National Sys- tem may be summarised as follows: No rivalship or jealousy should be indulged, and can- 200 PHYSICIAN, PROFESSION, AND PUBLIC dor, probity, and all due respect should be observed toward the physician in charge; the attending physician should be the first to propose the necessary questions to the sick; the physicians should retire to a private place for deliberation; the attending physician should be the one to communicate the conclusion reached and the direc- tions agreed upon; theoretical discussions should be avoided; and the most scrupulous regard should be ob- served for the character and standing of the attending physician. Sometimes the consulting is asked by the attending physician to deliver his opinion directly to the patient or relatives. In such cases he should do so only in presence of the attending physician. In cases of interference, the rules of conduct are full and explicit, in ten sections, embodying, with the soundest precepts, many admirable rules of etiquette so necessary for the guidance of beginners, and for impressing upon them the fact that due ceremony is always becoming to physicians and that it should be strictly observed by them in their relations to each other and to their patients. The following is a brief abstract of these sections: Those enter- ing the ranks of the medical profession should found their expectations on the character of their education and not on intrigue or artifice; they should avoid paying friendly visits to patients under the care of other physicians, but if at any time some special business should demand such visits, the conversation should be confined entirely to the business in question, and no reference made to the treat- 201 MORAL PHILOSOPHY OF MEDICINE ment or to the nature of the patient's illness. Except in cases of emergency, or in consultation, or when a physi- cian has relinquished a case, or been duly notified that his services are no longer required, another physician should not take charge of a patient, and under no circum- stances should he criticise the conduct of the physician previously in charge. When called to an urgent case, in the absence of the attending physician, after doing what is immediately needed, he should resign the care of the patient to the family physician as soon as he comes. When, owing to the absence or sickness of the attending physician, another is called to prescribe for a patient, he should surrender the case to the family physician on his return. When visiting a sick person in the country, a physician is called, in an emergency, to see the patient of another physician, he should do what may be necessary, and then relinquish the case unless asked by the attend- ing physician to continue in consultation. A wealthy physician should not give advice gratis to the affluent, because his doing so is an injury to his professional breth- ren. When a physician who has been engaged to attend an obstetric case is absent, and another is sent for, if delivery is accomplished during his attendance, he is entitled to the fee, but should then resign the patient to the physician first engaged. Of differences between physicians, something of the past as well as of the present should be said. Until about forty years ago contentions, controversies, and petty quarrels among physicians were very common and often arose 202 PHYSICIAN, PROFESSION, AND PUBLIC from questions of priority of inventions or of methods of procedure in treatment and in surgical operations, or from difference of opinion, or from causes such as have led to the unfrequent disputes during the past three decades. But it cannot be said with truth that contentions among phy- sicians are of more frequent occurrence than among mem- bers of other professions. In point of fact they are less so, from the very nature of the physician's mission. He is too much occupied with benefaction to waste time and temper in profitless and vexatious quarrels. When, un- fortunately, they do happen and the public becomes aware of their occurrence, the effect is pernicious not only to the people and to clients who lose faith in, and respect for, their physicians, but to professional dignity and influence. Such quarrels are generally instigated and fostered by the gossip, disparagements, and misrepresentations of some indiscrete persons or of false friends of both parties. The credulous militants may have been but little if at all ac- quainted, perhaps because they were not members of any medical society, and therefore could not have realised how greatly are promoted the harmonious and friendly rela- tions of physicians by a good medical organization, especi- ally one that fosters the social element, notably the col- lation after each session, to give its members frequent opportunities to smooth their mental asperities by gentle mutual attrition, to make due allowance for individual peculiarities, and to cultivate the true spirit of charity, good will, and good understanding. Even the contro- versies arising from hypercriticism of medical writings are 203 MORAL PHILOSOPHY OF MEDICINE markedly less frequent than they were twenty years ago and this is owing chiefly to the more^intimate acquain- tance of physicians, cultivated through pleasing talks dur- ing the periodical collations, the private exchange of views and the better appreciation of each other's characteristics. The first section of the short and explicit sixth article, of the second chapter of the National System, very posi- tively enjoins the physicians engaged in a controversy or in a contention which they themselves cannot settle amicably, to submit it to the adjustment of a "court med- ical"; whilst the second section, both in letter and in spirit, insists upon a proper reserve in the proceedings of the "court medical," the constitution of which is indicated in the first section. In other words, it distinctly forbids that the professional lavatory be exposed to the public gaze, and commands that, when it does become necessary to expurge the peccadilloes of members of the fraternity, the cleansing be effected in the strictest privacy. Of pecuniary acknowledgments to physicians for their services, it may be well to say more than the short article on that subject seems, at first sight, to warrant. In the seventh article of the second chapter of the Na- tional System, the question of pecuniary acknowledgments of professional services rendered to the sick is treated with wise brevity; leaving all details to the adjustment of phy- sicians of particular towns or districts. It is as follows: "Some general rules should be adopted by the faculty, in every town or district, relative to pecuniary acknowl- edgments from their patients; and it should be deemed 204 PHYSICIAN, PROFESSION, AND PUBLIC a point of honor to adhere to these rules with as much uni- formity as varying circumstances will admit." In the abstract, of the National System,promulgated in 1903, the article in question appears as the third section of the sixth article of that abstract with the underscored changes and additions, as follows, under the heading compensation: "Some general rules should be adopted by the -physi- cians, in every town or district, relative to the mirimum pecuniary acknowledgment from their patients; and it should be deemed a point of honor to adhere to these rule« with as much uniformity as varying circumstances will admit." To the foregoing may well be added what Doctor Perci- val said, relative to fees, in the fifteenth section of his second chapter, as follows; "For it is obvious that an average fee, as suited to the general rank of patients, must be an inadequate gratuity from the rich, who often require attendance not absolutely necessary; and yet too large to be expected from that class of citizens who will feel a reluctance in calling for assistance without making some decent and satisfactory retribution. But in the consideration of fees, let it ever be remembered, that though mean ones from the affluent are both unjust and degrading, yet the characteristical beneficence of the profession is inconsistent with sordid views and avaricious rapacity. To a young physician, it is of great importance to have clear and definite ideas of the ends of his profession; of the means for their attain- 205 PHYSICIAN, PROFESSION, AND PUBLIC ment; and of the comparative value and dignity of each. Wealth, rank, and independence, with all the benefits resulting from them, are the primary ends which he holds in view; and they are interesting, wise, and laudable. But knowledge, benevolence, and active virtue, the means to be adopted in their acquistion, are of still higher estima- tion. And he has the privilege and felicity of practising an art, even more intrinsically excellent in its mediate than in its ultimate objects. The former, therefore, have a claim to uniform preeminence." Compensation and pecuniary acknowledgment need a brief examination tending to point out the difference and very essential distinction existing between the phrase pecuniary acknowledgment, and the word compensation which is so often used synonymously with pecuniary acknowledgment despite the fact that there frequently is very gratifying compensation without pecuniary acknowl- edgment, and as frequently abundant pecuniary acknowl- edgment without the least compensation. Pecuniary acknowledgment of a service is often made grudgingly or even offensively, whilst true compensation is always the result of warm manifestation, in words and deeds, of sin- cere gratitude for a service. No amount of gold lavished upon him ever can constitute a compensation to the de- voted physician for a great service rendered in a desperate case of illness. In such a case, the cancellation of the pecuniary obligation is a pure business transaction, while the real compensation comes from the expression of sincere gratitude on the part of the patient and his family, and 206 PHYSICIAN, PROFESSION, AND PUBLIC one of the great sources of felicity of the medical man who has made the distressed sufferer happy and caused general rejoicing in the family. A few cases taken from ancient history-in those times when physicians occupied a peculiar position-may well be produced in illustration of the point in question. Critodemus, the physician, doubtless was happily com- pensated by the attachment of Alexander and by the great confidence of that monarch in his honor and fidelity, but particularly when he saw him fearlessly swallow the draught which the King had been warned against as deadly. Among other remarkable instances of true compensation is that related by Procopius in the case of the eminent physician Tribunus who had cured the Persian King Chos- roes of a serious illness. Tribunus' services were then pecuniarily acknowledged in princely style; and when, some time after, he was again summoned in his professional capacity, Chosroes offered whatever he might demand; but instead of requiring gold, he asked for the release of some Roman captives. Chosroes, touched by the great physician's self-abnegation and patriotism, not only set free the few captives, but generously gave their liberty to three thousand more Roman prisoners, to the great grati- fication of Tribunus. Even in the beginning of their enlightenment the Ara- bians had a high appreciation of medical skill and were wont to show genuine gratitude for faithful services. Caliph Almanzor, taken seriously ill, sent for George Bachtishua, a Christian physician of high repute, to minis- 207 MORAL PHILOSOPHY OF MEDICINE ter to his ailment. When the Caliph was well, he dis- missed the physician with grateful thanks after giving him ten thousand pieces of gold and conferring upon him the highest honors. Bachtishua's son Gabriel, also a skilful physician, was summoned by Haroun al Rashid to treat his counsellor Giafar whom he cured in three days, and also effected a surprising cure of one of the favorites of the harem. The Caliph's pecuniary acknowledgment of these services amounted to five hundred thousand drachmae-equal to one hundred thousand dollars, but with much greater pur- chasing power. The Caliph further expressed his grati- tude by honoring him in various ways and appointing him to the office of first physician to the Court. The Avon philosopher keenly appreciated the difference and distinction between pecuniary acknowledgment and compensation, so well illustrated in "All's well that ends well," when the daughter of Gerard of Narbon undertakes the cure of the King's infirmity, and when the Sovereign not only recognizes her service with a precious gift but with much gratitude expressed in the noblest acts of devotion. Louis XIV., after a painful illness, not only acknowl- edged pecuniarily with true regal munificence the services of his physicians, but compensated them by many acts of gratitude, particularly one of them who was the victim of an ailment requiring a grave operation and who felt the great compensation of the King's grateful and kind atten- tion to him during his illness. 208 PHYSICIAN, PROFESSION, AND PUBLIC Very many examples might have been added of the in- teresting distinction of pecuniary acknowledgment and compensation; the first being a purely financial, the second an essentially moral obligation. The moralists define gratitude as a sympathetic appreciation of benevolence. They add that this sense of kindness done or intended is accompanied by a desire to return it, and as benevolence between man and man is a duty, gratitude is named a moral affection, that is, gratitude is a disposition, the exer- cise and cultivation of which is required by moral law. A brief statement of the relations of the profession and the public will be the concluding subject of this conference. The public is dependent upon physicians for the cure of disease and for sanitation, and physicians are dependent upon the public for their livelihood. This interdependence surely entitles physicians to know the medical laws gov- erning the public, and it entitles the public to know the laws governing physicians in their relations to the public. The fact of the National System of Medical Morals being framed for the enlightenment and protection of the public and of physicians is so well known that it is astounding to hear any thinking being say that "the public has noth- ing to do with these rules." The medical profession, which forms a fair proportion of all communities, has always been public spirited and free and generous in its gifts of useful information for the weal of the people and of the State, and will surely continue so to be. In all de- partments of City and State government the employees are duly and liberally paid for their services; not so the 209 MORAL PHILOSOPHY OF MEDICINE great majority of physicians who generally perform arduous duties without hope of pecuniary acknowledgment. The few that are salaried are entirely too modest in their just demands. It is, therefore, high time that members of the profession assert themselves and insist upon the same recognition of their labors as is accorded to men of other professions. The contributions in kind, that is to say, in the way of professional services, made by physicians, to hospitals and dispensaries, very greatly exceed in time and money value whatever, as if lay individuals, they might generously and liberally contribute pecuniarily. If paid as men of other professions are paid, they would gladly contribute moneys as others do, and their paid services would be much more highly appreciated than are the varied and exacting services they have so long performed gratuitously. In final rebuttal of the allegation that the public has nothing to do with, and should neither know of, nor care about, the laws governing the conduct of physicians, let it be said that this public is in constant multifarious rela- tions with those physicians who give so freely and gener- ously their services in dispensaries and hospitals which would all have to be closed if the physicians were to cease attendance and no other physicians would take their places. The public demands and obtains the best abilities, the greatest devotion and the hardest work of these phy- sicians whose services this public gets gratis but which it would surely appreciate much more highly if they were paid for. The public needs the best services of those devoted 210 PHYSICIAN, PROFESSION, AND PUBLIC physicians who, connected with local boards of health, are doing such excellent work in sanitation and who are so poorly paid for their valuable labor. Many large corpora- tions, which could not exist without medical aid, make but little recognition of this indispensable element of their existence; and so it is with every public institution where the services of physicians are absolutely necessary. The physician will never occupy the position to which he has a right in the community until he places a higher value on his services and, like members of other profes- sions, he insists upon due pecuniary acknowledgment of these services. To the questions pertaining to physicians holding public offices, and to the occasional relations of other members of the profession with newspaper correspondents, it is hoped that the following replies will suffice. A physician in public office who regards the spirit of sound moral precepts will not violate it in any particular; and unless his ordinary signature be indispensable, as in an official document, he would naturally sign-"The phy- sician in charge," or "The chief medical officer," etc., just as in the case of illness of a public personage, he would sign a bulletin-"The attending physician." Such provisions would be unnecessary in any system of medical law; its spirit is always rightly interpreted by high-minded phy- sicians whose acts are never indicative of bad taste or of a prurient desire for notoriety. Regarding interviews, except in extraordinary circum- stances, there is no valid excuse for the appearance of the 211 MORAL PHILOSOPHY OF MEDICINE interviewed physician's name. He should freely give the desired information, whenever of public import, on condi- tion that the interviewer say in his publication-"The above statement is from a reputable physician.'' The public is likely to be satisfied with such a declaration in a responsible newspaper. SUMMARY What the physician shall do and what he shall not do for the honor, dignity, and advancement of the profession, and for the public weal. i. Exert your best abilities to maintain the dignity, honor, and high standing of the profession. 2. Strive to extend the bounds of its usefulness and to contribute abundant materials to enrich the science and art of medicine. 3. Obey all laws instituted for the government of the profession. 4. Observe proper respect for your seniors. 5. Be temperate in all things. 6. Be loyal to your brother physician in cases of interference. 7. Do not indulge rivalship or jealousy in consultations, but be fair, candid, considerate, and respectful to your colleagues. 8. Beware of all contentions and controversies. 9. Avoid newspaper notoriety, which is so much sought by charlatans. 212 PHYSICIAN, PROFESSION, AND PUBLIC io. Be as diligent in your public as in your private labors, and let them be of such a character as to merit the approval of the profession and of the public. 11. And remember that it is the duty of the associated physicians of a community to inform the public of the nature of its obligations to the medical profession. 213 XIII THE LANGUAGE OF MEDICINE Correct, simple, concise, and clear medical language as essential to the conduct of oral or written discourse as the cultivation of the senses is to the study and practice of medicine-Some of the medical writers of the nineteenth century-The young physician beginning to write for publication-Word contro- versy-The misusage of words-Wrongly coined words- Frequent revisions of essays-The early drilling of students in the use of words of precision. IV hat has the language of medicine to do with principles of conduct? The answer to this query is-very much indeed, for it will be perceived, in the course of this conference, that the observance of correctness and precision in medical language is as essential to the proper conduct of oral or written dis- course as the cultivation of the senses is to the study and practice of medicine. All doubts on this subject will speedily vanish if the periodical medical literature of the day be only cursorily examined and compared with the admirable writings of masters of the past, one of whom went so far as to say substantially that the sciences are reducible to exact language. The writers on medicine use a language which possesses sufficient peculiarities to merit special consideration, al- though it does not differ very greatly from that of some 214 THE LANGUAGE OF MEDICINE other branches of science. Like the language of those branches, its main requirements are accuracy, conciseness, clearness, and simplicity. The accomplished medical wri- ter does not ordinarily use florid language, does not indulge in what is miscalled fine writing. His well chosen words; his full diction; his elegant, lucid, simple style; his artistic descriptions; his happy illustrations; his exactitude of statement; his careful arrangement and skilful presenta- tion of a subject, together never fail to entertain the reader and to keep awake his interest. Many of the writers who flourished during the first half of the nineteenth century were richly endowed with these precious qualities; notably Watson the admirable teacher, and Carpenter the eminent physiosophist. Watson's celebrated lectures on the prac- tice of medicine, so accurate in technical language and so pure and elegant in style, continued to be the chief text book many years after his death. It was finally replaced by the more modern excellent works of Aitken, Flint, and of other eminent writers in different tongues. Of late, with but few honorable exceptions, too little attention has been given to the literary side of medical works. Their short survival will be due chiefly to linguistic defects; so, the coming generation of physicians will do well to emulate the high literary tone and the glory of the noble pioneers of the last century. IVhen the young physician begins to write for publication, his main difficulties are: the brief, simple statement, the proper arrangement, and the right presentation of his sub- ject. It is only by diligent labor and constant, close at- 215 MORAL PHILOSOPHY OF MEDICINE tention that he can overcome these difficulties. In under- taking the review of books he is often at a loss to under- stand the meaning of many queerly coined terms which he does not find in standard lexicons. His attention is di- rected also to the many misused and inappropriate words, to the strangely constructed sentences, to the vicious locu- tions, and to other linguistic incongruities; chiefly in periodical literature. He is therefore anxious for a criterion of intelligible medical writing, although he is aware that even the profoundest scholars have always found it diffi- cult to describe, define, and name things so accurately as to enable the reader to form the right conception of the author's meaning; and although he is aware also that to name an object rightly it is essential to know its nature, and therefore that to name is to know. Of course he is familiar with the old sayings that the true progress of science must always be realised in names, and that the perfection of a science depends, in no inconsiderable degree, upon the perfection of its language, and the per- fection of every language, upon its simplicity and precision. He knows too, that the present language of medicine is derived largely from the Latin and Greek tongues, and that, although the Latins borrowed much from the Greeks, it is scarcely justifiable or in good literary taste to compound Latin and Greek words. So he is con- stantly on the alert to avoid verbal hybridism, conscious as he is that there are already so many hybrid terms whose use will probably be continued until the logophilists of the end of this twentieth century shall have effected a radical 216 THE LANGUAGE OF MEDICINE reform in the language of medicine. It is therefore in- cumbent upon this generation of devoted laborers in the science to do the pioneer work of hewing down the vast forests of rank growth of error both in matter and in the manner of conveying the nature of the matter to the reader's mind. The young writer will fully appreciate the great impor- tance of precise language, in medicine, toward the avoid- ance of serious misunderstandings and bitter contentions, if he cast a glance at what is written on the subject of word-controversies by some of the philosophers and logo- philists among whom may be cited Stewart, Rosmini, Mill, Max Muller, and others of the past. Of word-controversies, Sydney Smith said: "Definition of words has been commonly called a mere exercise of grammarians; but when we come to consider the innumer- able murders, proscriptions, massacres, and tortures, which men have inflicted on each other from mistaking the meaning of words, the exercise of definition certainly be- gins to assume a more dignified aspect." Of misused words, the eminent logophilist Doctor Rich- ard Grant White said: "The misuse of words confuses ideas and impairs the value of language as a medium of communication. Hence loss of time, of money, and sore trial of patience. It is significant that we call a quarrel a misunderstanding. How many lawsuits have ruined both plaintiff and defendant, how many business connections have been severed, how many friendships broken, because two men gave to one word different meanings! The power 217 MORAL PHILOSOPHY OF MEDICINE of language to convey one man's thoughts and purposes to another, is in direct proportion to a common consent as to the meaning of words. The moment divergence be- gins, the value of language is impaired; and it is impaired just in proportion to the divergence, or to the uncertainty of consent." In nearly all the departments of medicine, said the mas- terly writer Cabanis, the language is ill-constructed. It has been more and more corrupted by the false application of words borrowed from the other sciences, and by a cer- tain insignificant jargon which has too often been adopted by physicians owing to a culpable respect for popular prejudices." So great indeed is the number of inappropriate, incor- rectly coined, and misleading terms used in medicine that often it is difficult for investigators writing in the same tongue to understand each other. It has frequently hap- pened that two discoverers have described the same sub- stance, process, or morbid state, under entirely different names, and that such names, perhaps unsuitable in either case, have caused much perplexity and unbecoming contention. Another evil arises from the sad verbal bankruptcy which leads many authors to call diseases and surgical procedures by the names of men. The attention of writers has been invoked repeatedly to the ill effects of these caconyms, but all arguments against them have been unheeded. Again recently the " Evil of Eponyms," was very justly and ably decried by Doctor George L. Richards in an address, pub- 218 THE LANGUAGE OF MEDICINE lished in the Journal of the American Medical Association for Oct. io, 1903, in which, speaking of certain surgical operations designated solely by the names of their origina- tors, he said: " By the time Jones' operation has been two or three times modified by Smith and Brown, and is inac- curately described by Robinson who refers to it as Jones' operation, Jones himself would probably deny it as his child. If every operative procedure were described in anatomic terms, no confusion could arise, and the reader of an article would know exactly what was meant by the author. It might take a few more words now and then, but this would be more than compensated for by the clearness of description which would of necessity result." Then comes the lame excuse about the "sanction of long usage" so generally offered by those writers who have not the courage to reject a wrong expression simply because it has been "so long in use." This is almost equivalent to sanctioning a wrong act because, for a long time, it has been habitually committed by evildoers. Anent the question of usage, hear what Doctor White said: "Usage ... is not, as it is often claimed to be, the absolute law of language, and it has never been so with any people-could not be, or we should have an example of a language which had not changed from what it was in its first stage, if indeed from such a law there could be a first stage in language The truth is, however, that the authority of general usage, or even of the usage of great writers, is not absolute in language. There is a misuse of words which can be justified by no 219 MORAL PHILOSOPHY OF MEDICINE authority, however great, by no usage however general. And, as usage does not justify that which is essentially unreasonable, so is the fact that a word or phrase is an innovation, a neologism, there is nothing whatever to deter a bold, clear-headed thinker from its use. Other- wise language would not grow. New words, when they are needed, and are rightly formed, and so clearly discrim- inated that they have a meaning peculiarly their own, enrich a language, while the use of one word to mean many things, more or less unlike, is the sign of poverty in speech, and the source of ambiguity, the mother of con- fusion." Other modern logophilists justly denounce this irrational plea for "sanction of long usage" of incorrect words; one of them saying substantially that, what in language is so often miscalled usage does little with reason, more without reason, and MOST contrary to reason. Since language originated with the untaught and was extended by the unlettered, it is not strange that its evo- lution should have been so slow, and its defects and inac- curacies so many. Even if from the beginning all men had been learned, it is not likely that any language of the present would be absolutely pure and precise, for language deteriorates as men deteriorate. And this deterioration, which is still going on, has, so far, resisted the efforts to repress it by modern logophilists among whom was Disraeli who pointed out its chief causes so tersely. There are, he said, "three foul corruptors of language; caprice, affecta- tion, and ignorance." These and other causes can surely 220 THE LANGUAGE OF MEDICINE be removed by teachers and men of letters who, by labor- ing diligently, will be likely to subdue these plagues upon literature; to repair some of the damage already done; to give proper training to the young; to encourage the cultivation of the five literary senses indicated by Balzac, namely: invention, style, thought, knowledge, and senti- ment; and particularly to foster that refined fireside edu- cation of the young, the effects of which are so patent in adult life. It is well known that the views of sound thinkers are not always expressed in as exact phrases as it was possible for them to employ, and that the fault is undoubtedly due chiefly to carelessness. Many good speakers and writers, occupied mainly with the matter of their discourses, are inattentive to the manner so essential to the clear and proper statement of the matter; using certain forms of expression correctly and then, soon after, incorrectly, often in the same speech or even in the same paragraph and it frequently happens that of the essays of eminent authors, while many are written in faultless style, as many are marred by the grossest errors of inadvertence. Spuri- ous words, vulgarisms, ungrammatic phrases, pleonasms, ill-constructed sentences, obscure statements, and other blemishes, abound in the works of the best writers of fic- tion, travel, history, philosophy, and medicine, owing mainly to obstinate carelessness, and despite the fact that their attention has been repeatedly called to these flaws by able critics of whose admonitions they remain obdu- rately heedless, and besides seemingly disregard, or take 221 MORAL PHILOSOPHY OF MEDICINE little or no interest in, the carefully prepared works on the proper use of words. The philosophers and logophilists quoted in this confer- ence are all agreed that ''a strict adherence to propriety in the use of words is the only means for maintaining clear- ness of ideas, for preserving and harmonising them." None more than poets realise the value of well-selected words and of their rhythmical ordering. Thus James Howel characterizes them. " Words are the soul's ambassadors, which go Abroad upon her errands to and fro; They are the sole expounders of the mind, And correspondence keep 'twixt all mankind." And Byron says of them: " But words are things; and a small drop of ink, Falling like dew upon a thought, produces That which makes thousands, perhaps millions, think." It is only after some experience in writing for publica- tion that young physicians learn to select the words most suitable to their theme, and to construct phrases and sen- tences which are not susceptible of misunderstanding; and learn also how important it is to revise, revise, revise, to alter, to amend, to correct, and anon to REVISE, not only the manner but the matter, in order that they may expunge utterances which, otherwise, they would regret ever to have reduced to writing. It is not so bad to say too little as too much, and it is the height of the art to say 222 THE LANGUAGE OF MEDICINE just enough and tell it well. "True ease in writing comes from art, not chance," says Pope. Francis Bacon rewrote all his philosophical essays; some of them eight, ten, or even twelve times. Voltaire said that he had spent nearly half of his literary life in writing, and the other half in cor- recting his writings. Mill wrote his "Logic" three times. Many of the best modern authors have had the same kind of experience and have fully realised that "hard writing makes easy reading." Howsoever great may be the profundity of his erudition, a careless writer's ill-chosen words and vague and am- biguous sentences are always at the mercy of captious critics who invariably misinterpret his meaning. It is very common for those guilty of the most glaring errors in the use of words to strive to advantage them- selves behind the shallow trench and frail palisade of "custom and long usage," when it is so evident that these specious pleas, which never can become laws in any tongue, constitute the weakest defense of the many inaccurate expressions that could never have belonged to the letter or spirit of the English language. Long usage, by the peo- ple, is too often ill usage since the popular masses are known to be so incompetent to decide nice questions in linguistics; and good usage, which necessarily implies accuracy, can emanate only from the lettered. The plea of "long usage" begets the toleration of countless vicious locutions and of the grossest misuse of terms, such as anticipate for expect, calculate for intend, commence for begin, considerable for much, a couple for two, experience 223 MORAL PHILOSOPHY OF MEDICINE for feel, observe for say, function for use, guess for believe, had better for should, inauguration for installment, locate for settle, partially for partly, patron for client, reckon for suppose, right smart for almost anything, and many hosts of kindred expressions which only serve to confuse and impoverish the language. The young writer will do well to abstain from the use of those inelegant and superfluous locutions such as "at any rate," and many others of the same genus that can only mar his style. The following are among the more commonly misused medical terms by writers and speakers: Adherence for adhesion (and vice versa). Allude for mention or refer. Apt for liable or likely. Anticipate for expect. Autopsy for post-mortem examination or necropsy. Avocation for vocation. Being done for is doing or is done. Beside for besides. Catheterization for catheterism. Circulatory system for circulatory apparatus: the vascu- lar system being a series of vessels belonging to the circula- tory apparatus. Considerable for much. Couple of days for two days. Curious for queer (a man may have curiosity, not a thing). Diagnose for diagnosticate. Elicit (to) for cause (to). 224 THE LANGUAGE OF MEDICINE Etiological factor for etical factor. Experience pain for feel pain. Had better for should. Healthy for wholesome or for healthful. I propose for 1 purpose. Locate for settle. Located for seated, situated, settled, or established. Met with for met or found. Militate for at variance. Morphology for morphism. Morphologically for morphicly. Most for very. Nicely for well. Obnoxious for objectionable. Observe for say. Once in a while for sometimes. Partially for partly or in part. Pathological changes for pathic or morbid changes. Patron for client. Practitioner for practiser, or practising physician. Presence for existence. Previous to for previously to. Psychologic for psychic. Psychological for psychical. Restive for restless. Section for region. States (he) for he says. Those who for they that. Transpire for occur. 225 MORAL PHILOSOPHY OF MEDICINE Where for in which. Where for when. Whether or no for whether or not. Since it would consume too much of the present time to enter into a discussion on all of the misused words or the incorrect phrases contained in the foregoing Index Expurgatorius, and since the remedy is applied so closely to the evil in each case, but a few of the words in question will be chosen for special examination. "To diagnose," although, by high authority, long ago declared to be incorrectly coined and unfit to take the place of to diagnosticate, has been advocated, of late, but without the warrant of sound argument; the main plea for its use being brevity. Surely it is not by a short term in a sentence that brevity is attained in the expression of an idea, but by the use of the fewest rightly chosen words. "To diagnose'' was not formed from the Greek infinitive diagignoskein or from the noun diagnostics, and no satis- factory derivation of the term appears in authoritative works, such as the Century Dictionary where it is set down as signifying to diagnosticate. Since it does mean to diag- nosticate, assuredly it is superfluous, and will be so regarded by logosophists all of whom are agreed that only necessary words should be coined, otherwise language would soon be encumbered with useless terms. The art of discrimina- tion came to be expressed, by the commentators of the Hippocratic and Galenic works, in the word diagnostics from which arose the adjective diagnostic-as in diagnos- tic signs-whilst the discriminator was designated diag- 226 THE LANGUAGE OF MEDICINE nostes, diagnostician. In the early part of the nineteenth century diagnose was used, by the French, as a feminine noun (la diagnose}, to signify the knowledge acquired by the observation of diagnostic signs (signes diagnostiqu.es}, but they also made use of diagnostic (le diagnostic}, as a masculine noun, and diagnostique as adjective. The ad- vocates of "to diagnose" would be inconsistent unless they should use diagnosian or diagnosist instead of diag- nostician which they do use, and also unless they should use to prognose, prognosian, or prognosist, instead of to prognosticate, prognostic, prognostication, prognostician. Practitioner is condemned by logophilists because they regard the coinage of this word as altogether unwarranted, there being no such a verb as to practition. Exactly when "practitioner" crept into the English language is not very clear. The word occurs in Captain John Smith's works which appeared during the first quarter of the seventeenth century, and also in Minsheu's "Guide into the Tongues," 1627. No less a writer than Jonathan Swift afterward used the word, whose employment may have begun with those English medicine men who kept drugs and per- formed minor operations in a shop which they styled "the surgery," and who called themselves "general practition- ers." The term seems to have been accepted by the regu- lar profession of medicine, in England without demur and without remembering that the word "practician" had already been in use, and that the redundant er had been suffixed and at length rejected. It is possible that the expression arose from the wrong enunciation of "practi- 227 MORAL PHILOSOPHY OF MEDICINE cianer" into "practitioner." Physician was commonly spelled "physitian" or even "physition" in old times. The advocates of "practicioner" or of "practitioner," to be consistent, should countenance "physicianer, physi- tioner, diagnosticianer, diagnostitioner, obstetricianer, obstetritioner, electricianer, electritioner," etc., etc. In Rabelais' Gargantua Chapter LIV., the following occurs: "Cy n'entrez pas, maschefains practiciens." Practiser, designating one who practises something, re- quires qualification-as a medical, a legal practiser, or a practiser of medicine or of law. However, good writers often regard the substantive as sufficient by itself; the context suggesting the right qualification. The following references may serve as evidence that practiser is not a neologism, since it was used two centuries before "practi- tioner" appeared in John Smith's works. The verb to practise is found in the writings of John Wyclif, during the second half of the fourteenth century. Practiser, in the form of the times is set down in Piers Plowman: "Till he was parfit practisoure if any peril felle." Chaucer's "Prologue to the Canterbury Tales" contains the word with k instead of c, and without the final e: "He was a parfit praktisour." Practiser occurs in Raleigh's " History of the World." Ben Jonson has "Detractors and prac- ticers against them"; using the c. In Shakespeare's "All's Well That Ends Well," 2. i., the King says to Helena, who offers to cure his infirmity: " Sweet, practiser, thy physic I will try." 228 THE LANGUAGE OF MEDICINE In his "Othello," i. 2., the noun is repeated: " A practiser of arts inhibited and out of warrant." That great master of language used the verb in many differing significations, as, "Sirs, 1 will practise on this drunken man"; meaning to play a trick upon him. "My uncle practises more harm to me"; that is, meditates more harm. "You have practised upon the easy-yielding spirit of this woman"; etc., etc. In the noun he sometimes substitutes c for the s. Beaumont and Fletcher and other writers of their time used practise, practice, practicer. In the King James Bible the 5 is invariably used in prac- tise. Good writers have, ever since, used practise and practiser. Notwithstanding the declaration of a recent critic that practiser is an innovation, it is plain that the word has been in use for the past five centuries by the best writers. In an attempt to defend the use of "practitioner," a physician, citing certain publications, said: "It will not do to use the word physician all the time; therefore, to avoid repetition, "practitioner" is substituted." Exam- ination of those and other publications showed the most sparing use of the word physician, whilst they contain abundant repetitions of "practitioner." This is a fair example of the introduction and frequent reiterations of a bad word to avoid the repetition of a good word. Doctor Richard Grant White, in his excellent work on "Words and Their Uses," published in the year 1871, said, under the head "words that are not words," that "Prac- titioner is an unlovely intruder, which has slipped into 229 MORAL PHILOSOPHY OF MEDICINE the English language through the physician's gate. We have no verb practition to be made a noun expressive of agency by the affix er. But either practitioner or practi- tionist means only one who practises, a practiser. Phy- sicians speak of their practice, and of the practice of medicine, and in the next breath call a medical man a practitioner. The dictionary makers give practise as the stem of practitioner-it is difficult to see why. The word is evidently the French praticien, which has been Anglified first by distortion, and then by an incongruous addition, in the hope of attaining what was unattainable-a word meaning something bigger and finer than is meant by the simple and correct form practiser." Practitioner is clearly a wrong expression which, as Dr. White says, is not a legitimate word. But since practiser requires a qualifier as medical practiser it seems best, if only for brevity, to adhere to the simple term physician; physic having been defined, by the highest authorities in logophily, as a science which treats of the nature of the human body, of the preservation of health, and of the cure of disease. Patron for client is perhaps the most unwarrantable of the misused words. No tradesman of any pretention ever thinks of styling his customers patrons, yet some physi- cians, high in repute, are wont to use this word in speak- ing of their patients or clients, although it is well known that patron is now applicable only to him who bestows gratuities on the poor, or contributes to the support of charitable enterprises. Originally kings, fathers of their 230 THE LANGUAGE OF MEDICINE people, were the patrons, the protectors of their satraps who were the kings' clients, and these in turn patronised, protected, underlings to whom they distributed gratuities, and who were their clients. In this age the client is he who pays for the counsel which he seeks. The physician is often a liberal patron of charities but has no patron. He gives advice and succor to the sick and injured who are his clients, his patients, just as those to whom the lawyer gives advice are his clients, not his patrons, and just as those to whom the clergyman gives spiritual con- solation and advice are his penitents and not his patrons. Therefore the physician should not speak of patronage but of clientage. The French have generally used the word clients to designate their patients, and of clientelle, or clientele as a collective term, which seems to have suggested the English word clientage which is assuredly more proper than patronage. Of patron, Doctor White said: "If you are in retail trade, don't call your customers your patrons, and send them circulars asking for a continuance of their patron- age; unless you mean to say that they buy of you, not because they need what you have to sell, but merely to give you money, and that you are a dependent upon their favor. There is patronage in this country, both within and without the administration of government; and it does not imply loss of independence on the one side or arrogance on the other; but it does not consist in buying what one needs for one's own comfort or pleasure." A few of the inappropriate strictly medical terms need 231 MORAL PHILOSOPHY OF MEDICINE a passing glance. As the nature of some diseases becomes better known, new names are substituted for the old which are'not definitive, so that, ere long, many of these incongruous terms will be obsolete; as apoplexy, aneu- rosis, cancer, carcinoma, catarrh, chlorosis, cholera, epi- lepsy, glaucoma, gout, hydrophobia, lunacy, malaria, plague, rheumatism, scrofula, and very many other words which only serve to perplex beginners and to retard the progress of medicine. " The exactness of names and the uniformity of terms render more facile and prompt the knowledge of a science, and an expressive and characteristic denomination makes a profound impression upon the mind which necessarily puts the object designated into the place of its designa- tion." Such were the views of Condillac as paraphrased by Pinel. Another sound thinker said: ''It is the exact- ness and also the good use of words, or more generally of signs, which should be considered as the criterion of the truth; it is to their vague character, to the uncertain and confused manner in which they are employed, that should be attributed imperfect notions, prejudices, errors and all vicious habits of the mind." In his writings, the well-trained beginner will not con- found description and definition if he remember that the description of a disease is the setting forth, in detail, of its cause, nature, patho-anatomy, and symptoms; whilst the definition of a disease is the statement of its peculiar, dominant, and constant characteristics so concisely and clearly that it can be readily recognised; and that there- 232 THE LANGUAGE OF MEDICINE fore an exact definition is the summary of an accurate description; that it takes from such description only what is essential to precisely characterize a disease and distin- guish it from any other disease; that an exact definition can therefore be deduced from the analysis only of a com- plete description; that in the description of a disease there may be characters which are common to two or to more than two diseases; and that to include such charac- ters into a definition would vitiate and render it useless. He will not forget that the language of medicine should be euphonious, simple, clearly expressive, and accurate, for, its object is not only to describe and define diseases with precision, but to mirror and chronicle the medical experience, wisdom, and genius of the past as well as the present; that nosographic nomenclature is the most im- portant part.of medical language, consisting as it does of the technical terms therein used; and that this nomencla- ture should be based upon the structural characters of the affections of the human body; therefore the names given to diseases should convey to the mind an exact idea of the morbid conditions which these names are designed to express, at least a strong endeavor should be made toward the attainment of that end. The prudent young scholar will tactfully avoid verbal encounters with the vulgar and never unsheath his intel- lectual weapons against those gigantic word-mills that perpetually grind out all manner of literary heresies. Neither will he seek to reform the whole world of writers and speakers with whom he may be at variance, but 233 MORAL PHILOSOPHY OF MEDICINE simply maintain his right to express himself correctly in speech and in print, for it would be fruitless to attempt the demolition of the impregnable works of the relentless enemy of good language that has been engaged so long in perverting and torturing the English tongue, in mystify- ing human understanding, and in shocking the refined taste of discerning readers. Good mental discipline, pa- tient investigation, harmonious labor, and mutual encour- agement, will surely be of the greatest help to all who may be engaged in the laudable attempt to purify the language of medicine, particularly if each laborer bear in mind the adage that "nothing strengthens a man more than the confidence of others in his capacity to do." As means to the desired end, students of medicine should be thoroughly drilled in the use of words of precision whose employment is coupled with exact knowledge; not for- getting that to name is to know-for, the words name and know have been traced to the same root whose antiquity is nearly as great as that of man-and exact medical knowledge, methodically arranged, will assuredly lead to its practical application in the cure or in the alleviation of human suffering, and in the preservation of public health. 234 XIV YOUNG PHYSICIANS AS WRITERS AND SPEAKERS How to master the art of intelligible medical writing-The use and abuse of figures of speech-Word coining-Obsolete words-Misusage of terms-Alliteration-Florid writing out of place in medicine-Quotations-Short and long sentences -The proper disposition of members of sentences-The good of frequent revisions-Punctuation-Medical " bulls"-Style -Titles of essays and books-Individual titles-Preface- Introduction-Epigraph-A few cautionary remarks for the benefit of young speakers. Although, during the last conference, some suggestions relating to his compositions were made to the young medi- cal writer and speaker, a few additional hints may prove serviceable to him who doubtless knows that the art of putting together words intended to express his thoughts and compel their right apprehension by the reader or listener, cannot be acquired without long study beginning from childhood at the family hearth. He knows it is at the home fireside that the first educational principles are indoctrinated and that so many useful ideas are impressed upon the child's developing mind. There he is told of the necessity of rightly understanding the meaning of all the words which he uses; and later he is taught the sage maxims to the effect that "He who would gain a knowl- edge of men must first learn to understand the meaning of words''; and that "Among the most important con- 235 MORAL PHILOSOPHY OF MEDICINE cerns of men are the right names of things and exacti- tude." With such a fund of preliminary notions, the boy is able to profit greatly, during adolescence, in the acquire- ment of the knowledge exacted for his admission to the freshman class in a University. His four years of labor are soon passed and he has grown to manhood, ready to begin the study of medicine, and in due time to enter the ranks of the profession and gradually build up a practice. After some years of experience and study he naturally realises that it is his duty to contribute a fair share of lore to medical societies and journals or in the form of a trea- tise. The work will give him very great pleasure if his early training have been such as to enable him to over- come promptly the difficulties so often encountered in the composition of serious literary essays. But even then he should devote an abundance of time to the cultivation of the difficult art of writing intelligibly which is attainable only through a thorough knowledge of the properties, value, and different shades of meaning of words, and the ability to construct symmetrically and harmoniously all phrases, sentences, paragraphs, and chapters of the work undertaken. It is solely by long, patient, and persever- ing labor that he can acquire mastery in this art which necessitates such mature thinking, such close attention to matter as well as manner, and so much general reading, besides critical annotations of suggestive passages from the best works of eminent authors. Only when he has gone through this kind of exercise of his mental faculties has the beginner learned to avoid the use of forms of 236 YOUNG PHYSICIANS AS WRITERS speech which are not in accord with refined literary taste, and only then does he realise that the best style of com- position must depend upon great wealth of diction, wise judgment in the selection of words the most appropriate to the subject of a particular discourse; concise and clear in expression of thoughts; excellence in description; brev- ity and exactness in definition; accuracy in statement; felicity in illustration; fitness in arrangement; and pro- priety in the presentation of a subject. He feels quite sure that there is no facile path toward the attainment of this art, and that there is no exaggeration in the old say- ing-"Easy writing's curst hard reading." He also very naturally concludes that the man who boasts of being able to write with great ease and of never revising, is very likely to be a poor writer whose easy writing makes the hardest kind of reading. One of the great writers of the nineteenth century, in a letter of advice to a young liter- ary friend, said substantially: 1 notice in your last essay that you expressed an excellent idea, but in scarcely suit- able words, and am certain that you would have made a better choice had you not been in too great haste. Be sure hereafter to take more time and pains to find the right words, and especially to avoid so-called equivalents which, as you know, often obscure the intended meaning and so create serious doubts. This is one of the many examples that may be given of the necessity, of the im- portance of correct verbiage. The beginner does not find it easy to resist the tempta- tion of over using certain figures of rhetoric in his composi- 237 MORAL PHILOSOPHY OF MEDICINE tions. Hence the necessity of cautioning him and of in- sisting that very few of these figures should ever take place in the language of medicine. Among the figures regarded with favor in good medical writing are similes, metaphors, and allegory, all of which, however, to be used very sparingly. Similes, though sometimes helpful, sel- dom appear in short essays of good writers. Metaphors used in excess mar and inflate medical language, their effective employment requires ripe judgment and long experience in the art of writing. Allegory, generally unj safe and of difficult usage, is occasionally resorted to with some advantage. The careful writer, striving for lucidity, generally uses words and phrases susceptible of but a single meaning, so he is rarely obliged to say of a particular expression that he has used it in one or in another sense. He seeks the right names of things and rejects eponyms as he does sonorous, big, empty words; those "words of learned length and thund'ring sound,'' which should be banished from all serious medical discourses. The pomposity of such words renders their use and user ridiculous in the extreme. However, the use of long compound words is sometimes necessary to avoid circumlocution, particularly in purely technical articles, as in anatomy, in bio-chemics, and in chemistry. The coinage of words is attended with such risks that the young writer should not think of undertaking the delicate difficult, and thankless task until the subject of a discourse renders it absolutely necessary. When he does build up 238 YOUNG PHYSICIANS AS WRITERS such a necessary word let him be sure of its freedom from the slightest linguistic imperfection. His caution will be the greater if he remember what Ben Jonson said on this question: "A man coins not a new word without some peril, and less fruit; for if it happen to be received, the praise is but moderate; if refused the scorn is assured." Obsolete words need some notice. There are many good words which, generally from un- known reasons, have been declared obsolete but are still found in the lexicons with the mark "obsolete." When- ever such words seem to him the most appropriate to the subject of his discourse, the writer should not hesitate to employ them. Alliteration, used parsimoniously, is serviceable when it is desirable to express an idea with increased emphasis; otherwise it is best when only incidental. Its use is too often excessive, not so much in medical as in general liter- ature. Poe gives a notable example of the effect of skil- fully used alliteration in his "Raven"; but the most remarkable instance of profuse alliteration is in the face- tious Latin poem bearing the title " Pugna Porcorum," and consisting of upward of three hundred verses in more than seventeen hundred words; each word beginning with the letter p, even in the footnotes. Florid, sophomoric, "fine writing'' is out of place in the language of science and even in fiction. An eminent critic once spoke of his own former fondness for this style; say- ing that when he began to set forth his thoughts he was wont to state a simple fact by the use of a great profusion 239 MORAL PHILOSOPHY OF MEDICINE of euphonious words; giving an example substantially as follows: "The noble mansion in which I first inhaled the invigorating ambient air and playfully and peacefully passed the most delighting days of my mundane existence is, at this sad moment, in a startling state of inflammation." And he was greatly pleased with the alliteration; but after having learned to write, he said that he should have conveyed the information as follows: "The house in which 1 was born is on fire." Quotations, to illustrate or confirm a statement, ordi- narily should be brief, or made in abstract with precision and accuracy. But sometimes it is necessary to quote whole paragraphs. Sentences, properly arranged, greatly enhance the liter- ary value of any work. The artistic writer studiously avoids continuous short, jerky sentences as well as many successive sentences of medium length and also extremely long sentences. Those of the first category distract atten- tion by the littleelectroid mental shocks which they cause; those of the second are monotonous; and those of the third are tedious, exhausting to the reader's mind, and of difficult apprehension. An example of extraordinary macrology is to be found, in one of the works of an eminent medical writer, in the form of a sentence covering seven octavo pages and containing four thousand two hundred words; the highest sign of punctuation being the semi- colon, with an occasional dash. Good literary taste de- mands that, in any work, there be judiciously interspersed short, medium, and long sentences. 240 YOUNG PHYSICIANS AS WRITERS To convey meaning with precision and clearness requires no little care and attention; but even then errors of mo- mentary inadvertence sometimes occur, in the disposition of members of certain sentences, which make the writer express the opposite of what he had intended to say. An example may be drawn from a sentence in this very con- ference; the fault was detected on the first revision. The sentence was originally as follows: "He rejects eponyms and seeks the right names of things as he does sonorous big, empty words." The real intention was to say: He seeks the right names of things and rejects eponyms as he does sonorous, big, empty words. It is only by repeated careful revision that such and many other errors of inad- vertence are detectable; the reviser looking also for faulty punctuation which so often mars the best writings. Punctuation, rightly used is of much importance to the writer or speaker who, of course, is desirous of being clearly understood, for he knows that the omission of a dash or a comma has been known to change entirely the meaning of a sentence; as exemplified in the oft-quoted instance of the offering of a toast at an entertainment, as follows: "Woman-without her, man would be a savage." When this reached the printing house, it was set up as follows: "Woman without her man would be a savage." A mark of punctuation which merits attention and which is much used by the Spanish, is the inverted inter- rogation point at the beginning of an interrogatory sen- tence besides the regular mark at the end of the sentence; and so with the exclamatory. This would be serviceable 241 MORAL PHILOSOPHY OF MEDICINE in making easy and smooth the reading of any English composition wherever the first word does not clearly in- dicate the interrogatory or the exclamatory character of the sentence. A writer cannot be too particular in his use of signs of punctuation, which are so essential to the right apprehension of his expressions and to the avoidance of confusion in the mind of the reader. Parentheses are not generally necessary to the writer who has the skill to frame sentences which clearly express his thoughts. The young writer, therefore, should train himself so thoroughly that he will seldom be obliged to use explanatory parenthetic phrases or sentences, which are so wearisome and so much distract attention. A prolific writer of three decades ago contracted the habit of over-using parentheses and went so far as to crowd parenthetic phrases into parenthetic sentences. His works were thus rendered extremely tedious and of laborious perusal, though they possessed merit. The bracket as well as the dash should be but rarely used. The first chiefly in purely technical articles. On paragraphs, only a few suggestions relating to their construction are needed for the guidance of young writers. They may be short or as long as necessary for the elucida- tion of the main points. A paragraph may embody one or several thoughts expressed in one, two, or several sentences with any required illustration. Among the preceding paragraphs is a fair example which con- tains the expression of several thoughts ending with an illustration. 242 YOUNG PHYSICIANS AS WRITERS Extremely long paragraphs, on careful revision, may be divided with advantage to the reader. If this be done at the close of a complete sentence it will not disturb the train of thoughts sought to be conveyed. These very long paragraphs, like sentences of inordinate length, are sometimes so tedious to the reader as to require their division even when the main points cannot all be given in paragraphs of moderate length. Illustrative examples, when consisting of several sentences, may be placed as separate paragraphs. The observance of these cautions tends to prevent verbosity. Let it be remembered that the first paragraph of an essay is of difficult composition and its initial sentence still more difficult, requiring to be rewritten several times; and that therefore too much at- tention cannot be given to this exordium which, if good, will make, or otherwise mar the whole work. Medical "bulls," which sometimes occur in written as well as in oral discourses, require but a few moments' attention. These "bulls" often excite loud demonstra- tions of mirth among the listeners to a speech, much to the confusion and embarrassment of the unconscious perpetra- tor, but the habitual offender, ever unaware of his "bulls" is wont to attribute the levity of the auditors to some intended affront and forthwith makes a worse "bull" during the by-speech expressive of his indignation. One of the learned men in the profession, an inveterate "bull- ist," once said to a friend that he had just come from an alarming post-partum haemorrhage in the case of Doctor John Jones, the house-physician. The listener, being a 243 MORAL PHILOSOPHY OF MEDICINE junior, suppressed incipient laughter for fear of giving offense. This same chronic "bullist," a charming and much-loved man, published an elaborate and interesting paper illustrated by many rare instances and artistic drawings, ending with the expression of much regret that he was not able to furnish more data, since "post-mortem examinations had been made only on the fatal cases." When his attention was called to the "bull," by an inti- mate friend, he said, of course post-mortem examinations were made only on those patients that had died! These two examples typify his innumerable bulls which many of his surviving friends are wont to rehearse. A word in regard to style. The avoidance of the evils decried, and the observance of the suggestions made, in the foregoing remarks, are essential to the perfection of the art of intelligible writing. But the beginner generally wants something more; he is overanxious about the ac- quirement of style which, however, he soon learns, is not to be sought outside of the individual himself, and which the accomplished writer Buffon characterized so succinctly: "Le style c'est I'bomme." Indeed the nature of the man scarcely ever fails to show itself in the style of his writings. The vivacious, the excitable, the querulous very generally leave in their writings traces of their peculiar characteris- tics, as do the forceful, the exact, the refined, and as do the pompous, the bombastic, the pretentious. And this, notwithstanding the degree of their technical knowledge, or of their mastery in science and letters, of their wealth of diction, skill in the choice of words variations in modes of 244 YOUNG PHYSICIANS AS WRITERS expression, or accuracy in description. He knows that style is defined, in the lexicons, as a method of expressing thought by selection and collocation of words; determine by the subject, the period, the nationality, the individual- ity, the mode of presentation, etc. And he may remem- ber Jonathan Swift's definition of style in five words: " Proper words in proper places." He will do well to note what two nineteenth century philosophical writers said so briefly on this subject: "The best style is that which offers the least resistance to thought." "La perfection du style doit etre recbercbee de tons ecux qui se croient appeles a rependre des idees utiles. Le style, qui n est que la forme appropriee au sujet par la reflexion et Tart, est le passe- port dont toute pensee a besoin pour courir et prendre gite dans tous les cerveaux.'' Of titles of essays or of books much may be said, but, for the present, a few words will suffice. Long titles as well as long prefaces and tedious introductions should be avoided. The titles of many of the medical works, pub- lished as lately as the eighteenth century, nearly filled a whole page, and the titles were generally followed by dedicatory epistles, notes to readers, prefaces, prolego- mena, etc., in each case making up no small part of the treatise. Many of these books have become mere curi si- ties of literature. At present the space is somewhat better filled, although the prefaces and introductions are often too long. The title of any essay or book, and even a sub- title which is seldom desirable, will the better serve its purpose by being brief, for, this quality and the appro- 245 MORAL PHILOSOPHY OF MEDICINE priateness of the words used are important factors in the success of a work. Therefore, very great attention should be given to the composition of the whole title page. This task is not generally undertaken until all the chapters have received their titles. Such vague and inappropriate titles as-An interesting case, A unique case, Unique cases, Unusual features, and many others of the same genus so very frequently occurring in periodic medical literature, should be studiously avoided. Long titles are quite as undesirable, and any title which exceeds ten words may be regarded as too long. Careful examination of several thousand current journal articles revealed the fact that in one-third of these articles the titles exceed ten words and ranged up to twenty, twenty-five, thirty, thirty-five and even forty words. This excessive unsightly verbiage is evidence either of extreme careless- ness or of an unconscious abstraction of a great part of the article to make up what proves to be a tedious title, and surely denotes lack of skill in composition. As sub-title, there is a hackneyed phrase which the young writer should invariably reject, and that is: "With special reference to," followed by a string of words belonging to the text of his essay. Such a sub-title is not only super- fluous, and an offense to the perception of the reader, but is marring to the title page whose simple, becoming dress should be a sufficient indication of the general character of the work. A stilted ostentatious title is often sugges- tive of the poor work of a vain pretender. Individual honorary titles should be few, for, the parad- 246 YOUNG PHYSICIANS AS WRITERS ing, as of old, of a great profusion of such certificates of proficiency is not indicative of good taste, and serves only to deface the title page. Two or three titles after the M.D.; as membership of prominent associations, or of insti- tutions of learning, are generally regarded as sufficient vouchers of professional status. The epigraph is also often suggestive of the character of a work and sometimes of its writer. It may be almost the summary of a work, as so well illustrated on the title page of "Violette's Chemical Manipulations." The quo- tation is from Benjamin Franklin, as follows: "A good workman should be able to saw with a file and file with a saw." Violette's whole book is full of excellent sugges- tions to young chemists as to the extemporisation of neces- sary apparatus. The epigraph should therefore signify the general nature of the work, otherwise, better none than an inappropriate epigraph which would be useless or even ridiculous. Multiple significant quotations, or a short statement further indicating the purport of the work or defining some part thereof, may occupy the space op- posite the title page. The dedication, generally intended as a tribute of respect, affection, gratitude, to a near relative, to a loved master, to a dear associate, to a collection of friends, or to an eminent contributor of professional lore, should be brief and couched in simple language. The preface should state, in few words, the intent of the writer; two or three sentences generally sufficing. Pref- aces covering several pages are seldom read. 247 MORAL PHILOSOPHY OF MEDICINE The table of contents, which follows the preface, should include titles of chapters besides a succinct statement of the chief points of each chapter. The formal introduction or general outline of the subject of the book, needed mainly in the larger treatises, is gen- erally omitted in the lesser works. No part of a work is of more difficult composition than the introduction which should be undertaken by the author only after the copy is nearly ready for the press; as the careful study of the matter and manner of the work required for the prepara- tion of this introduction is almost certain to suggest some very important alterations in the text and perhaps a few additions. To chapters, the art of giving short, appropriate titles sel- dom exceeding six words, is acquired only by long practice. The brevity of such titles is a sure sign of the writer's skill in the composition of a work. The title of a chapter should be followed by a concise statement of the matter of the chapter or rather of the main points discussed; this statement serving also to make up the table of contents. The appendix, required in some works, should be men- tioned in the preface, and its contents given at the end of the general table of contents. Such an appendix some- times consists mainly of justifying pieces. The index should be confided to the care of a skilful indexer. As a final suggestion to the young writer, the following may have some value. Prior to the composition of even a short essay, the writer, if he have something useful to 248 YOUNG PHYSICIANS AS WRITERS impart, will surely save much time and extra labor by preparing a short syllabus of his article, and make notes on each separate heading. These notes to be written at convenient moments on such bits of paper as may be at hand, suitably docketted and ready for use in proper time and place. In general, the writing of all essays should be done in the early morning after breakfast while the mind is fresh. The sittings need not exceed an hour during which one duodecimo .page of thirty lines is composed. Revision of the manuscript may be done at night, but no composition. The task of a twenty-paged article is thus deliberately, thoughtfully, slowly, and accurately accom- plished in as many sittings without interfering with other labor. During the revision of the printed proof of the essay, the reviser should look particularly for pleonasm, verbosity, tautology, circumlocution, redundancy, besides such other blemishes as may be due to inattention to the manner while the mind was absorbed with the matter. Medical writing characterised by the precise, distinct, and unmistakable conveyance of ideas is the outcome chiefly of a judicious choice of words and phrases together with their skilful and harmonious disposition, and makes easy reading while it insures the right conception of the author's meaning. Essays containing such blemishes as the crowding of too many diverse ideas into a comparatively small space, and sameness in their mode of expression throughout suc- ceeding paragraphs are: in the first instance, overtaxing to mental assimilation; and, in the second instance, ex- 249 MORAL PHILOSOPHY OF MEDICINE tremely tedious in their monotony and suggestive of torpid literary sensibility. The aspiring young writer, who is constantly enriching his diction and who is able to clothe, in exact, terse, pure, and clear language, the statement of such notions as he may wish to impart, is sure to enlist the attention and interest of a large class of readers. But however carefully he may have studied the subject of his discourse, howso- ever elegant his style and correct his conclusions, he is not likely to escape the strictures of those captious critics who are ever seeking to discover what may have been omitted in any work whenever they fail to find flaws in the author's matter or manner. The strict observance of the very simple rules given in this and in several of the preceding discourses, and close attention to the suitable arrangement and attractive pre- sentation of the matter of his essays will assure their suc- cess and their approval by critical contemporaries and by discerning readers in the very distant future; particularly if he have taken the pains to acquire a pure and an abun- dant, exact, elegant diction free from floral decoration. He will then have attained the laudable end of compelling the right understanding of all the useful information he may seek to impart. To the young speaker, only a few more cautionary re- marks need now be addressed. His standing attitude should be natural, and his gestures rare and becoming; as any affectation in either case would be certain to prejudice his auditors. His voice should be clear, not loud, his 250 YOUNG PHYSICIANS AS WRITERS speech deliberate, and his enunciation distinct with the strictest observance of the rules of orthoepy. He should not declaim, but reason; he should forbear artificial man- nerism; and eschew what is commonly styled "speech to the gallery.'' In the discussion of a question raised at a gathering of physicians, he should not talk of his experience in this or that particular, but state modestly and simply such facts as he may possess or such conclusions as he may have reached from the observation of cases of disease. Under no circumstances whatsoever should the speaker transgress the amenities of debate by offensive utterances of any sort or by inordinate censure, but be content to refute views which he may regard as erroneous, and do so in the most considerate tone, after having taken occasion to commend, without ostentation or patronage, all that is good in his opponent's discourse, and never wander from the main question under debate. He should not make use of those popular locutions which are so ludicrous besides being indicative of poverty of dic- tion. The chief among these vicious locutions are: "To speak frankly; in this connection; he was free to confess; that at this juncture; an occurrence which transpired; contrary to the anticipation of his patrons; was quite a little surprising." Above all he should never use slang expressions. His personality should be sunken in the subject of his discourse, just as the personality of the truly great actor is always lost in the character which he interprets. So 251 MORAL PHILOSOPHY OF MEDICINE would the personality of the medical orator be absorbed in the character of the phenomena which he is endeavoring to interpret, if he modestly abstain from the use of the pronoun of the first person singular, and from giving his opinion instead of conclusions reached by careful examina- tion of a subject, for, a mere opinion has little value as against the general consensus of the learned. If young writers and speakers accept the guidance of this particular conference, they cannot fail to make their contributions intelligible and otherwise profitable to read- ers; and if all loyal physicians will live up to the broad principles set forth in the rest of these conferences and give their earnest help toward effecting a solid, stable, union of the medical profession, their efforts will be crowned with the richest success, and they will have every reason to be proud of belonging to one of the most power- ful national many-branched organizations whose just de- mands will not be denied in any part of this vast land, whilst membership of such a body, representing science and beneficence, will assure to each of its votaries the greatest public respect and the highest consideration. 252 xv LENGTH OF LIFE OF PHYSICIANS To live long and be useful the physician must begin his career by living rightly-Mortality among physicians between the ages of twenty-one and forty-Average length of life of the physician-The question of retirement from practice and other work-Advanced age per se not a condition necessarily disqualifying a medical man from professional duties- Senility not to be measured by length of years but by infirmi- ties of body and mind-Longevity among eminent physicians -Examples of physical and mental activity in aged physi- cians-No good reason for retirement except physical or mental disability. Young physicians, naturally desirous to know what is likely to be their length of life and how long they should continue to labor in the practice of medicine, are soon made aware that a life of license and dissipation almost always shortly ends disastrously, and that to live long, and continue to be useful, they must begin their career by living rightly. This early beginning, made during student life, renders the good student a worthy candidate for longevity, since he is seldom ill, and leads a sober and regular life; having sought and followed the soundest hygienic precepts and being impressed with the idea that good health is essential to the usefulness of the young as well as the aged physician. He therefore employs the best means of preventing disease and preserving health, 253 MORAL PHILOSOPHY OF MEDICINE and is generally successful in his struggles against those evils that hasten premature senility; remembering what Cicero said in his essay on old age which should be fought as a disease; that sage recommending sobriety and mod- erate physical and mental exercise without which the body and mind decay as a lamp not duly supplied with oil. He also remembers Seneca's words in his discourse on the shortness of life. " If it be well employed," he says, " life is sufficiently long. It becomes short when squandered or ill spent." So the life and usefulness of the laborer in medicine is likely to be long if he always observe modera- tion in exercise, food, drink, sleep, study, and in all things. However, the mortality among physicians, between the ages of twenty-one and forty is known to be so great as to make the average life of the medical man shorter than that of some of those engaged in other pursuits, but this sad bill of mortality, carefully examined, will generally show that very many of the recorded deaths have occurred from preventable diseases as well as from accidents not a few of which were due to heedlessness. Of 229 deaths (betweent the ages of twenty-one and forty), whose causes were stated in a late mortuary report, 137 were from the following named causes: thirty-five from tuberculosis, twenty-five from typhoid fever, forty-five from pneumonia, and thirty-two from accidents. Toward the close of the second third of the nineteenth century the average length of life of physicians was sup- posed to be thirty-two years, and down to the end of that century it had risen to thirty-five years. This increased 254 LENGTH OF LIFE OF PHYSICIANS average was due probably to clo; er observation of hygienic rules, and suggests still further advancement of the average in the course of another period of thirty years. But should physical and mental examination of all applicants for matriculation in the medical schools be soon exacted, on the lines indicated in the third conference, and the students be early taught private hygiene and general sanitation, the physicians' average length of life will doubtless be still greater partly owing to decrease in the number of deaths from preventable diseases, and, in all likelihood, there will be more hearty octogenarians among physicians in the latter part of this twentieth century than ever before. The well-trained graduate spends the greater part of his first ten years in study, observation, and the accumu- lation of experiences such as are gained in public institu- tions and in a moderate private practice. During the succeeding ten years he is in the most active period of practice and is then likely to be overworked, and too often, as it were, burn his mental and physical candle at both ends, and to be too venturesome. He is fortunate who can be restrained by some kind friend and adviser that had already reached the third decade, that period of greater discretion and wise conservatism. The physi- cian's work, both practical and scientific, is generally of a better sort and of greater value when he is between the ages of fifty and seventy than ever before, and his literary and philosophic labors may be continued until he is far advanced in years. 255 MORAL PHILOSOPHY OF MEDICINE The frequently asked question-at what age the physi- cian should retire from active practice or from the profes- sion-has been answered so diversely as to leave the inquirers in perplexity, and therefore requires further consideration. In civil practice, and in military and educational insti- tutions, the suggestions concerning the age for retirement of the physician seem to have been made, in general, with- out due regard to the state of body and mind of the individual alleged to be unfit for duty. In the case of civil practice, some opinions, unsupported by sufficient reasons, have been expressed that the physi- cian ought to relinquish his professional labors at sixty, and others at seventy or seventy-five years of age. In the navy, the age fixed for retirement is sixty-two, and in the army sixty-four years. But in either case the medical officer, at any time after his retirement, may be called upon to perform certain duties unless he be totally disabled. In American universities, no age limit for retirement of professors seems to have been adopted; while in some European universities the professors have been retired at sixty and even fifty-five years of age, whereas formerly they were appointed for life. In 1902 the professors of the school of medicine of Paris could retire voluntarily at seventy, except those who were members of the Institute who could not demand retirement before the age of seventy- five. In public and private hospitals, the medical attendants 256 LENGTH OF LIFE OF PHYSICIANS in some cases, retire voluntarily after many years of faith- ful gratuitous labor, and in other cases are retired at a time when their services .are of the greatest value to the institutions. So much is asserted arbitrarily about mental deteriora- tion beginning at the age of fifty, that the question is very properly asked-Does disability or decrepitude, mental or physical, belong to any special age of men? A brief inquiry into the subject of macrobiosis among eminent physicians may be helpful toward the categoric answer to this and also to the initial question. However, an endeavor, will first be made to show that it is scarcely reasonable to regard advanced age per se as a condition which necessarily disqualifies a medical man from the per- formance of his labors. The young physician who bears constantly in mind that days, weeks, months, years, come in quick succession to add to his own age, and that he may live to pass the three score and ten years allotted to man, is likely to view this subject calmly and rationally, and to be happier and wiser for treasuring the sentiments so admirably expressed in the following Alexian lines done into English verse: " Man's nature doth in much resemble wine, For young men and new wine do both need age To ripen their too warm unseason'd strength, And let their violence evaporate. But when the grosser portions are worked off, And all the froth is skimm'd, then both are good, The wine is drinkable, the man is wise. And both in future pleasant while they last." 257 MORAL PHILOSOPHY OF MEDICINE The young, strong, unripe mind, unless duly restrained, often leads to venturesome, rash or even reckless measures, until the grosser, exuberant, frothy notions are eliminated by experience. However, the well-trained junior physi- cian, blessed with vigorous bodily health and good habits, who only gradually attains mental maturity-precosity being too often fatal to advance-is likely to reach a green old age during which to be useful and to perform, with certainty and efficiency, the duties for which he is best fitted. Surely senility ought not to be measured invariably by length of years but by bodily and mental infirmities. In support of this view is the attestation of trustworthy records of the many who have reached very old age without serious impairment of body or mind. The Avon thinker showed well how he appreciated this fact when he pictured an octogenarian temperate in habits, old in appearance, but young in action: "Though I look old, yet I am strong and lusty; For in my youth 1 never did appiy Hot and rebellious liquors in my blood, Nor did not with unbashful forehead woo The means of weakness and debility, Therefore my age is as a lusty winter, Frosty but kindly let me go with you; 1'11 do the service of a younger man In all your business and necessities." History records so many ocotgenarians and nonagene- rians who, retaining their vigor of body and of mind, were able to do the work of younger men, that they can scarcely be regarded as extremely rare exceptions. It is true that, 258 LENGTH OF LIFE OF PHYSICIANS commonly, after the age of fifty the tissues of the body are more or less hardened, and it is equally true that the process of induration is generally long deferred in persons who lead a regular and sober life and are free from any grave disease; but general sclerosis with physical and mental decrepitude, this premature senility, which so often begins at a very early age, is ordinarily due to dis- ease or to debauchery. The examples are very many of physical and mental caducity in men who, scarcely reach- ing their second score of years have rendered themselves unfit for any kind of labor, and there is no lack of instances of early disability among those chronic deboshed who, at fifty years of age, shifting into the lean and slippered pantaloon, with shrunk shank, shuffling gait, piping voice, and enfeebled mind, are on the verge of that last stage of existence, that second infancy, "sans teeth, sans eyes, sans taste, sans everything." A glance is worth taking at another portraiture by the great master, in the boldest strokes of his potent pen, of a common variety of prema- ture senility from debauch, to wit: "a moist eye, a dry hand, a yellow cheek, a white beard, a decreasing leg, an increasing belly, a broken voice; the wind short, the chin double, the wit single, and every part blasted with an- tiquity." So many physicians die in early manhood from injuries or from diseases contracted in the line of duty that longev- ity, as computed by vital statisticians, is not to be sought in the profession of medicine; nevertheless, the number of physicians who pass three score years in good health is 259 MORAL PHILOSOPHY OF MEDICINE greater than generally supposed. In all probability many more deaths occur among physicians than are reported in the medical journals which generally give but incomplete information, so that exactness of statement is not attain- able from the analysis of the recorded cases, not only as regards numbers, but age and cause of death. However, some idea may be formed of the duration of the life of physicians from the mortuary records of one year during which the death of 1974 physicians was announced, and this is a fair average annual statement. Of these 1974 deaths, the age could not be computed in eighty cases; leaving 1894 to be examined. Of the 1894 deaths, 1003 occurred between the ages of twenty-one and sixty; and 891 between the ages of sixty-one and ninety-eight. Of the 1003 deaths, 49 occurred between the ages of twenty- one and twenty-five; 91 between twenty-six and thirty; 96 between thirty-one and thirty-five; 134 between thirty- six and forty; 151 between forty-one and forty-five; 144 between forty-six and fifty; 149 between fifty-one and fifty-five; and 189 between fifty-six and sixty. Of the 891 deaths, 174 occurred between the ages of sixty-one and sixty-five; 198 between sixty-six and seventy; 186 be- tween seventy-one and seventy-five; 153 between seventy- six and eighty; 120 between eighty-one and eighty-five; 46 between eighty-six and ninety; and 14 between ninety and ninety-eight years. A fact worthy of special note is that, many of the oldest had been men of great eminence as physicians and teach- ers; nearly all dying in harness. 260 LENGTH OF LIFE OF PHYSICIANS It may also be noted that many thousands of phy- sicians past seventy and even eighty years of age, still in active practice and doing excellent work, are flourish- ing in this and other countries. Close students of macrobiosis are agreed that those live longest who exercise both body and mind in moderation, and that the outcome of their well-directed labor is gener- ally substantial, of a high order, and lasting. Biographic and other records verify the assertion that men of culture, whose health and habits are good, do not deteriorate mentally but rather improve with age, and these records further show that such men have always striven to be abreast or even in advance of their time. Hence the old saying-"the more learned a man grows, the better organ- ized is his mind." As early as sixty or sixty-five years of age, some physi- cians choose to discontinue general practice; preferring to occupy themselves in consultations with younger men, or to devote their leisure hours to such studies as are likely to lead to advances in medicine, to the betterment of the profession, to the maintenance of public health, and to other useful ends. Therefore, whilst they may early relinquish active private practice, they need never retire from the profession unless disabled by some serious disease or accidental injury. There are very many notable examples to uphold the view that men of science do not generally deteriorate mentally after the age of sixty. The biographies give many thousands of instances of great mental activity in 261 MORAL PHILOSOPHY OF MEDICINE physicians who, from the age of sixty to sixty-nine, were performing the best and most laborious professional duties and contributing valuable lore. And there are also many records of physicians who had passed sixty-nine years in sound and active mental condition. Some instances be- longing to this category, gathered from published obituary sketches, are now given in further testimony. Eight hun- dred and twenty-five cases were analyzed with the follow- ing results. Of these 825 cases-chiefly American phy- sicians-271 were between seventy and seventy-four; 241 between seventy-five and seventy-nine; 195 between eighty and eighty-four; 83 between eighty-five and eighty-nine; 30 between ninety and ninety-four; and 5 between ninety-five and ninety-eight. A few special instances of physical and mental activity of physicians in advanced life, gathered from divers sources may be worth noting. The father of medicine is known to have accomplished his best philosophic and literary work in advanced life when he composed the great books of aphorisms and prognostics; laboring to the end. Of the place, Larissa, of his death all biographers are agreed; not so of the time which has been given at from seventy-five to one hundred and four years. According to Soranus the age of the mas- ter was eighty at the time of his death. Galen too, wrote on prognostics, and also on antidotes, and on the development of the foetus, during the latter part of his life which lasted seventy years as says Suidas, and one hundred and forty according to other writers. 262 LENGTH OF LIFE OF PHYSICIANS Avenzoar, master of the celebrated Averrhoes, was one of the most learned of the Moro-Spanish physicians of the twelfth century. He continued his professional labors until he had reached the great age of ninety-two, when he passed away. Arnauld de Villeneuve, who died in 1313 at the age of seventy-eight, laboring to the last days of his life, is spoken of as one of the greatest physicians of his time in France. Jean Pitard, of whom mention has already been made in connection with the Paris College of Surgeons, died in 1315 at the age of eighty-seven while still laboring dili- gently and effectively. Jacques Dubois (Jacobus Sylvius) the consummate an- atomist and popular teacher, colleague of Fernel and mas- ter of Vesalius, labored until 1555 when he died aged seventy-seven years. The great Ambroise Pare, father of modern surgery, who practised his profession in civil and military life dur- ing the reigns of Charles IX. and Henry 111., and whose works are so well known, lived to the age of eighty- two. Caesalpino, so prominent in anatomy and botany during the sixteenth century died at the ripe age of eighty-two. Fabrizzio d'Acquapendente, the renowned anatomist and surgeon, master of the illustrious Harvey, died at the age of eighty-two in May, 1619, too soon to be gladdened by the wonderful discovery of his worthy English pupil 263 MORAL PHILOSOPHY OF MEDICINE who later in that same year, 1619, first disclosed the results of his researches in the blood circulation, and who lived to the age of seventy-nine years enjoying the verification of his doctrines. Du Verney, the great comparative anatomist and zoolo- gist, was still laboring at the age of eighty and continued his investigations two years longer when he died. Vander Straten, an eminent teacher of anatomy and accomplished physician lived to the years of eighty-eight. Jean Louis Petit, the illustrious surgeon, lived seventy- six years, laboring and teaching. Morgagni taught anatomy and medicine during sixty years in the Padua University and died full of honors at the age of eighty-nine. His pupil, Scarpa, who became professor of anatomy and surgery at Pavia, died at eighty-five. Heberden, the accomplished scholar, great physician, and excellent man, reached the age of ninety-one in the full possession of his mental power. Ruysch, the celebrated professor of anatomy at Leyden, continued his lectures until he had reached the age of ninety-one when, having sustained a fracture of the thigh, he caused himself to be carried into the amphitheater whence he took leave of his loving pupils, but he lived three years after the sad accident. Fr. Bayle lived eighty-seven years; J. F. Helvetius,, eighty-four; Pringle, seventy-five; Cullen, seventy-eight; Callisen, eighty-four; Pinel, eighty-one; Portal, ninety; Sir Astley Cooper, seventy-three; Sir Benjamin Brodie, 264 LENGTH OF LIFE OF PHYSICIANS seventy-nine; and Weurth, ninety-eight, continuing in active work to his last days. Doctor Chevreul, the great French chemist, died in his one hundred and third year. In June 1904 died, at Montpellier, France, Doctor David at the age of one hundred and three years and six months. He had been in the active practice of his profession up to his ninety-eighth year. In July 1904 it was reported that Doctor Meurisset of Noyon had completed his hundredth year a few months before. Our own countryman, the learned physician, righteous man, and ripe scholar, Doctor Edward Augustus Holyoke of Salem, the first president of the Massachusetts Medical Society, one of the brightest ornaments of the profession of medicine, was born on the first day of August in the year 1728, and died on the thirty-first of March, 1829, at the great age of one hundred years and eight months. The remote cause of his death was a slight accident. " He was stepping into his two-wheeled 'shay' and his foot slipped on the icy iron step and scraped the skin from his shin and the wound refused to heal." It was the conse- quent confinement, probably, that hastened his death, as such has been known to do in the case of aged persons who, like the doctor, having led a life of great activity are sud- denly obliged to be quiet owing to some injury. Anatomic examination showed all his internal organs to be in a normal state. Doctor Holyoke was of short stature, wiry, energetic, and physically and mentally active to the last. 265 MORAL PHILOSOPHY OF MEDICINE His memory was good, his eyesight excellent, but his hear- ing somewhat impaired from the age of eighty. " He had the quiet dignity of a gentleman of the old school which was very winning to his friends and acquaintances, and prevented any familiarity or rudeness from strangers." His habits had always been regular, he was a sound night sleeper, a good smoker, and seems to have been a believer in the ancient saying that wine is the milk of old age, for he drank it wisely, and made moderate use of spirituous liquors highly diluted. He had a large correspondence to which he attended after nine o'clock at night, as his whole days were devoted to other pursuits; continuing as a con- sultant until the time of the injury and subsequent con- finement which hastened his death. He was beloved as a true man, venerated as a faithful citizen, and prized as a great physician and benefactor. The greater part of this sketch is abstracted from a communication kindly sent by a great grandson of the deceased. The following additional notes, relating to longevity among eminent American physicians of the eighteenth and nineteenth centuries, may not be without interest. Zabdiel Boylston, of Brookline, Mass., who introduced inoculation against the smallpox in America, and whose other great deeds are so well known in his native State and the whole country, lived to his eighty-seventh year, beloved for his noble character and respected for his high professional attainments. The elder Shippen, of Philadelphia, who lived eighty- 266 LENGTH OF LIFE OF PHYSICIANS nine years, was a man of the highest integrity and a true patriot, besides being an accomplished and faithful physician. John Redman, the first president of the College of Phy- sicians of Philadelphia, a man of extraordinary tact, activ- ity, and professional ability, lived to the age of eighty- four notwithstanding delicate health. James Lloyd, the learned physician and devoted patriot, lived to the age of eighty-two revered for his lofty moral standard and esteemed for his medical skill. James Craik lived eighty-two years; Adam Kuhn, sev- enty-five; John Jeffries, seventy-six; A. R. Cutter, eighty- five; Hugh Williamson, eighty-five; Nathaniel Peabody, eighty-two; John Manning, eighty-seven; /Eneas Mon- son, ninety-two; Elihu Tudor, ninety-three; John Beatty, seventy-eight; Nathaniel Coffin, eighty-two; and Samuel Danforth, eighty-eight years. Samuel Bard, who lived and labored to the age of sev- enty-nine years, was a man of the highest literary and professional attainments and of exemplary moral attri- butes. In his studies, said his biographer the Reverend John McVickar, he was guided by his noble father Doctor John Bard, one of the great physicians of the eighteenth century, who lived to the age of eighty-four. A portion of Doctor Bard's letter to his son, who was on the eve of sailing for Europe, there to prosecute his studies, is worth reproducing for the benefit of young physicians. "With regard, my dear Sam, to your moral conduct, I do not flatter you when I assure you that I have the great- 267 MORAL PHILOSOPHY OF MEDICINE est confidence in your piety, prudence, and honor; still, a severe test of all these is now approaching since you are going to a part of the world where you will be surrounded with allurements. Your greatest security will lie in the first choice of your company. If, according to your former conduct, you associate with men of sense and business, of sobriety and honor, and with ladies of char- acter and family, your time will be most agreeably and honorably filled up between a course of business and of pure and refined pleasure. This will render all your cor- respondence with the world easy and delightful, and en- large your sphere of valuable connexions and friends." Doctor Bard fulfilled in the highest degree the fond expectations of his father. After spending five years abroad, one in London, and four in Edinburg under the tuition of Cullen, Monro, Ferguson, and other great mas- ters, he returned home to occupy a prominent position as citizen, physician and teacher. When in after years, he took up his residence in the country it was not with intent to lead an idle life but to change occupation; devoting much of his time to agricultural and other congenial pursuits. John W. Francis, of whose erudition, professional abil- ity, and admirable personal qualities mention has already been made, lived to the age of seventy-two years without the slightest sign of mental deterioration. The illustrious Valentine Mott attained his eightieth year; two years before which he was still engaged in active practice and performing grave surgical operations. 268 LENGTH OF LIFE OF PHYSICIANS John P. Batchelder, one of the veteran American sur- geons and teachers, full of originality and skill, was in active practice at the age of eighty-one. S. D. Gross, the able teacher of surgery and prolific writer, died at eighty-one. Oliver Wendell Holmes, the eminent teacher of anatomy, the genial man and great poet, lived to the age of eighty-five. Frank H. Hamilton, author of an exhaustive treatise on fractures and dislocations, and of other surgical works, continued his labors to the age of seventy-three when he died. Edmund Andrews, one of Chicago's eminent surgeons, lived seventy-nine years, teaching almost to his last days. Nathan S. Davis, father of the American Medical Asso- ciation, retained his mental power and labored to the end; passing away at the age of eighty-seven. Another instance of good work done in advanced life is that of the third Doctor Austin Flint who was in active practice and teaching at the age of seventy-four, and who, a few days before his death, completed the composition of his crowning work, a masterly address on "Medicine of the Future," which was to have been delivered before the British Medical Association. Its first paragraph, which has some pertinence to the subject of this conference, is well worth quoting. "The medical practiser whose retrospections extend over half a century may naturally be expected to revert to the past. To review the progress of medicine for fifty years. 269 MORAL PHILOSOPHY OF MEDICINE to make comparisons of the beginning and the end of that period, to revive the enthusiasm of by-gone days-these are among the resources of those who may be called medi- cal semi-centenarians. In the ability to look backward through so long a period, is to be found some compensa- tion for deprivations incident to the passage of one's life beyond youth and middle age. Retrospection has uses apart from this compensatory gratification; but, if too absorbing, it impairs appreciation of the present and faith in the future. To look forward, as well as backward, is both interesting and useful. If our retrospections extend over half a century, it is worth while to inquire, How will the present appear in a retrospective view at the end of the next fifty years? . . . That admirable production of an optimistic sage and seer is replete with the most interesting and valuable mat- ter stated in the best manner, and with grand predictions some of which were fulfilled not long after his death. The foregoing notes contain but a few examples of the very many physicians who have continued to be useful until far advanced in years, who, by their well-directed labors, have done so much for the science and art of medi- cine, whose good life and noble deeds have so endeared them to their clients and friends, and who have thus shed such great luster on the profession. In medical gatherings, the presence of elderly members is generally wholesome to juniors who so often learn from them many things pertaining to physicians besides the purely technical. Therefore the aged should not give up 270 LENGTH OF LIFE OF PHYSICIANS attendance upon the sessions of the societies. The good effects of free interchange of views amongst the young and old are keenly felt in scientific bodies, especially educa- tional institutions where are to be found many able teach- ers past sixty and seventy years of age who give the right tone and standing to the establishments with which their good names and high repute have been so long identified. The answer to the question of age limit respecting re- tirement from practice or from the profession may be summed up as follows: Although the time for retirement of navy and army medical officers is fixed authoritatively, provision is made for the employment of retired officers when there is need, and they still remain in the service and are subject to cer- tain regulations. In civil life, the physicians devoted solely to private practice who have reached an age which compels long rest from fatiguing labor, may still make themselves useful in consultations or in the examination of grave questions of private and public sanitation, besides other concerns neces- sitating mature experience, leisure, and the calmness and deliberation of age for their transaction. Hospital physicians, rather than being retired at sixty- five or seventy, while still strong and hearty, might well be assigned to the performance of special duties such as would be advantageous to those institutions. In universities, the retirement of efficient teachers, in robust physical and sound mental health, simply on ac- count of their being over three score years, is not likely 271 MORAL PHILOSOPHY OF MEDICINE ever to be of advantage to any school. It is fair that opportunity be afforded to younger professors to give in- struction in the elementary and practical branches of medicine, and, for this purpose, the old masters need not be shelved but transferred to such departments as they are judged best fitted to conduct. Let it be reiterated that so long as the true physician has health of body and vigor of mind, so long should he continue to make himself useful to humanity, to science, and to his guild, and that howsoever early he may choose to relinquish private or public practice, he should never retire from the profession until called to his last account. When the physician's "mind is not oppressed by care nor the body by sickness, his declining years often prove the happiest in his existence, and he finds in literature and other congenial pursuits the greatest comfort and solace." 272 APPENDIX NOTE For the convenience of future students of that part of the moral philosophy of medicine, which especially concerns the American medical profession, a few docu- ments, to serve in its history, are appended to the foregoing conferences. The order of arrangement of these pieces is as follows: I. The Hippocratic Oath and Law; II. The National System of Medical Morals; III. Re- marks on the National System; l.V. The Explanatory Declarations; V. Remarks on the Explanatory Declara- tions; VI. The Abstract of the National System; VII. Remarks on the Abstract of the National System; VIII. An Analysis of Dr. Austin Flint's Commentaries on the National System of Medical Morals. 275 1 THE HIPPOCRATIC OATH AND LAW The Hippocratic Oath and Law, constituting, as they do, the corner-stone of the moral edifice of medicine, should now be given to the student in their entirety; a part only of each having appeared in the conference on the evolution of medical morals. Careful perusal of this Oath and Law will show how greatly the framers of all statutes of medical institutions and of all systems of medical morals were indebted to these admirable productions of the master-mind of the Father of Medicine. The Oath* I swear by Apollo the physician, and /Esculapius, and Health, and All-heal, and all the gods and goddesses, that, according to my ability and judgment, 1 will keep this oath and this stipulation-to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to *The translation is that of Adams. 276 APPENDIX learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others. 1 will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterius and mischievous. I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion. With purity and with holiness 1 will pass my life and practice my Art. 1 will not cut persons laboring under the stone, but will leave this to be done by men who are practisers of this work. Into whatever houses I enter, I will go into them for the benefit of the sick, and will ab- stain from every voluntary act of mischief and corruption; and, further from the seduction of females or males, of freemen and slaves. Whatever in connexion with my professional practice, or not in connection with it, 1 see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret. While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times! But should I trespass and violate this Oath, may the reverse be my lot! 277 MORAL PHILOSOPHY OF MEDICINE The Law i. Medicine is of all the Arts the most noble; but, owing to the ignorance of those who practise it, and of those who, inconsiderately, form a judgment of them, it is at present far behind all the other arts. Their mistake appears to me to arise principally from this, that in the cities there is no punishment connected with the practice of medicine (and with it alone) except disgrace, and that does not hurt those who are familiar with it. Such per- sons are like the figures which are introduced in tragedies, for as they have the shape, and dress, and personal ap- pearance of actors, but are not actors, so also physicians are many in title but very few in reality. 2. Whoever is to acquire a competent knowledge of medicine, ought to be possessed of the following advan- tages: a natural disposition; instruction; a favorable position for the study; early tuition; love of labor; leis- ure* First of all, a natural talent is required; for, when Nature opposes, everything else is vain; but when Nature leads the way to what is most excellent, instruction in the art takes place, which the student must try to appropriate to himself by reflection, becoming an early pupil in a place well adapted for instruction. He must also bring to the task a love of labor and perseverance, so that the instruction taking root may bring forth proper and abun- dant fruits. * This evidently means that he should not have any other occupation to engross his mind or take up any of the time devoted to study. 278 APPENDIX 3. Instruction in medicine is like the culture of the productions of the earth. For our natural disposition is, as it were, the soil; the tenets of our teacher are, as it were, the seed; instruction in youth is like the planting of the seed in the ground at the proper season; the place where the instruction is communicated is like the food imparted to vegetables by the atmosphere; diligent study is like the cultivation of the fields; and it is time which imparts strength to all things and brings them to maturity. 4. Having brought all these requisites to the study of medicine, and having acquired a true knowledge of it, we shall thus, in travelling through the cities, be esteemed physicians not only in name but in reality. But inex- perience is a bad treasure, and a bad fund to those who possess it, whether in opinion or reality, being devoid of self-reliance and contentedness, and the nurse both of timidity and audacity. For timidity betrays a want of powers, and audacity a want of skill. There are, indeed, two things, knowledge and opinion, of which the one makes its possessor really to know, the other to be ignorant. 5. Those things which are sacred, are to be imparted only to sacred persons; and it is not lawful to impart them to the profane until they have been initiated in the mysteries of the science. 279 II THE NATIONAL SYSTEM OF MEDICAL MORALS This document takes place here for the reason that the whole of it did not appear in the foregoing conferences. It is therefore given in full as adopted, in the year 1847, by the American Medical Association. Doctor Hays, in presenting the report of the committee of framers of the document, said that justice required some explanatory remarks; and further said that the members of the convention would not fail to recognize, in parts of it, expressions with which they were familiar. On examining a great number of systems of morals adopted by different societies in the United States, it was found that they were all based on that of Doctor Percival, and that the phrases of this writer were preserved, to a considerable extent, in all of them, Believing that lan- guage so often examined and adopted, must possess the greatest of merits for such a document as the present, clearness and precision, and having no ambition for the honors of authorship, the committee which prepared this have followed a similar course, and have carefully pre- served the words of Doctor Percival wherever they con- vey the precepts it is wished to inculcate. A few of the sections are in the words of the late Doctor Rush, and one 280 APPENDIX or two sentences from other writers. But in all cases, wherever it was thought that the language could be made more explicit by changing a word, or even a part of a sentence, this has been unhesitatingly done; and thus there are but few sections which have not undergone some modification; while, for the language of many, and for the arrangement of the whole, the committee must be held exclusively responsible. The document as reported and adopted is as follows: Chapter I.-Of the Duties of Physicians to their Patients AND OF THE OBLIGATIONS OF PATIENTS TO THEIR PHYSICIANS. ARTICLE I.-DUTIES OF PHYSICIANS TO THEIR PATIENTS Section i.-A physician should not only be ever ready to obey the calls of the sick, but his mind ought also to be imbued with the greatness of his mission, and the responsibility he habitually incurs in its discharge. These obligations are the more deep and enduring, because there is no tribunal other than his own conscience to adjudge penalties for carelessness or neglect. Physicians should, therefore, minister to the sick with due impressions of the importance of their office; reflecting that the ease, the health and the lives of those committed to their charge depend on their skill, attention and fidelity. They should study, also, in their deportment, so to unite tenderness with firmness, and condescension with authority, as to inspire the minds of their patients with gratitude, respect and confidence. 281 MORAL PHILOSOPHY OF MEDICINE Sec. 2.-Every case committed to the charge of a phy- sician should be treated with attention, steadiness and humanity. Reasonable indulgence should be granted to the mental imbecility and caprices of the sick. Secrecy and delicacy, when required by peculiar circumstances, should be strictly observed; and the familiar and confi- dential intercourse to which physicians are admitted in their professional visits, should be used with discretion, and with the most scrupulous regard and fidelity and honor. The obligation of secrecy extends beyond the period of professional services; none of the privacies of personal and domestic life, no infirmity of disposition or flaw of character observed during professional attendance should ever be divulged by the physician except when he is imperatively required to do so. The force and necessity of this obligation are indeed so great that professional men have, under certain circumstances, been protected in their observance of secrecy by courts of justice. Sec. 3.-Frequent visits to the sick are in general requisite, since they enable the physician to arrive at a more perfect knowledge of the disease-to meet promptly every change which may occur, and also tend to preserve the confidence of the patient. But unnecessary visits are to be avoided, as they give useless anxiety to the patient, tend to diminish the authority of the physician, and render him liable to be suspected of interested motives. Sec. 4.-A physician should not be forward to make gloomy prognostications, because they savor of empiricism by magnifying the importance of his services in the treat- 282 APPENDIX ment or cure of the disease. But he should not fail on proper occasions to give to the'friends of the patient timely notice of danger when it really occurs; and even to the patient himself, if absolutely necessary. This office, how- ever, is so peculiarly alarming when executed by him, that it ought to be declined whenever it can be assigned to any other person of sufficient judgment and delicacy. For the physician should be the minister of hope and comfort to the sick; that, by such cordials to the droop- ing spirit, he may smooth the bed of death, revive expir- ing life, and counteract the depressing influence of those maladies which often disturb the tranquillity of the most resigned in their last moments. The life of a sick person can be shortened not only by the acts, but also by the words or the manner of the physician. It is, therefore, a sacred duty to guard himself carefully in this respect, and to avoid all things which have a tendency to discourage the patient and to depress his spirits. Sec. 5.-A physician ought not to abandon a patient because the case is deemed incurable; for his attendance may continue to be highly useful to the patient, and com- forting to the relatives around him, even in the last period of a fatal malady, by alleviating pain and other symptoms, and by soothing mental anguish. To decline attendance, under such circumstances, would be sacrificing to fanciful delicacy and mistaken liberality, that moral duty which is independent of, and superior to, all pecuniary con- sideration. Sec. 6.-Consultations should be promoted in difficult 283 MORAL PHILOSOPHY OF MEDICINE or protracted cases, as they give rise to confidence, energy and more enlarged views in practice. Sec. 7.-The opportunity which a physician not unfre- quently enjoys of promoting and strengthening the good resolutions of his patients suffering under the consequences of vicious conduct, ought never to be neglected. His counsels, or even remonstrances, will give satisfaction, not offense, if they be proffered with politeness, and evince a genuine love of virtue, accompanied by a sincere interest in the welfare of the person to whom they are addressed. ARTICLE II.-OBLIGATIONS OF PATIENTS TO THEIR PHYSICIANS. Section i.-The members of the medical profession, upon whom is enjoined the performance of so many impor- tant and arduous duties toward the community, and who are required to make so many sacrifices of comfort, ease and health, for the welfare of those who avail themselves of their services, certainly have a right to expect and re- quire that their patients should entertain a just sense of the duties which they owe to their medical attendants. Sec. 2.-The first duty of a patient is to select as his medical adviser one who has received a regular professional education. In no trade or occupation do mankind rely on the skill of an untaught artist; and in medicine, con- fessedly the most difficult and intricate of the sciences, the world ought not to suppose that knowledge is intuitive. Sec. 3.-Patients should prefer a physician whose habits of life are regular, and who is not devoted to com- pany, pleasure, or to any pursuit incompatible with his 284 APPENDIX professional obligations. A patient should, also, confide the care of himself and family, as much as possible, to one physician; for a medical man who has become acquainted with the peculiarities of constitution, habits and predis- positions of those he attends is more likely to be successful in his treatment than one who does not possess that knowledge. A patient who has thus selected his physician should always apply for advice in what may appear to him trivial cases, for the most fatal results often supervene on the slightest accidents. It is of still more importance that he should apply for assistance in the forming stage of violent diseases; it is to a neglect of this precept that medicine owes much of the uncertainty and imperfection with which it has been reproached. Sec. 4.-Patients should faithfully and unreservedly communicate to their physician the supposed cause of their disease. This is more important, as many diseases of a mental origin simulate those depending on external causes and yet are only to be cured by ministering to the mind diseased. A patient should never be afraid of thus making his physician his friend and adviser; he should always bear in mind that a medical man is under the strongest obligations of secrecy. Even the female sex should never allow feelings of shame or delicacy to per- vent their disclosing the seat, symptoms and causes of complaints peculiar to them. However commendable modest reserve may be in the common occurrences of life, its strict observance in medicine is often attended with the 285 MORAL PHILOSOPHY OF MEDICINE most serious consequences, and a patient may sink under a painful and loathsome disease, which might have been readily prevented had timely intimation been given to the physician. Sec. 5.-A patient should never weary his physician with a tedious detail of events or matters not appertain- ing to his disease. Even as relates to his actual symptoms, he will convey much more real information by giving clear answers to interrogatories, than by the most minute account of his own framing. Neither should he obtrude upon his physician the details of his business nor the history of his family concerns. Sec. 6.-The obedience of a patient to the prescriptions of his physician should be prompt and implicit. He should never permit his own crude opinions as to their fit- ness to influence his attention to them. A failure in one particular may render an otherwise judicious treatment dangerous and even fatal. This remark is equally ap- plicable to diet, drink and exercise. As patients become convalescent they are very apt to suppose that the rules prescribed for them may be disregarded, and the conse- quence, but too often, is a relapse. Patients should never allow themselves to be persuaded to take any medicine whatever that may be recommended to them by the self- constituted doctors and doctresses who are so frequently met with, and who pretend to possess infallible remedies for the cure of every disease. However simple some of their prescriptions may appear to be, it often happens that they are productive of much mischief, and in all 286 APPENDIX cases they are injurious, by contravening the plan of treat- ment adopted by the physician. Sec. 7.-A patient should, if possible, avoid even the friendly visits of a physician who is not attending him- and when he does receive them, he should never converse on the subject of his disease, as an observation may be made, without any intention of interference, which may destroy his confidence in the course he is pursuing, and induce him to neglect the directions prescribed to him. A patient should never send for a consulting physician without the express consent of his own medical attendant. It is of great importance that physicians should act .in concert; for although their modes of treatment may be attended with equal success when applied singly, yet con- jointly they are very likely to be productive of disastrous results. Sec. 8.-When a patient wishes to dismiss his physi- cian, justice and common courtesy require that he should declare his reasons for so doing. Sec. 9.-Patients should always, when practicable, send for their physician in the morning, before his usual hour of going out; for by being early aware of the visits he has to pay during the day, the physician is able to apportion his time in such a manner as to prevent an interference of engagements. Patients should also avoid calling on their medical adviser unnecessarily during the hours devoted to meals or sleep. They should always be in readiness to receive the visits of their physician, as the detention of a few minutes is often of serious inconvenience to him. 287 MORAL PHILOSOPHY OF MEDICINE Sec. io.-A patient should after his recovery, entertain a just and endearing sense of the value of the services rendered him by his physician; for these are of such a character that no mere pecuniary acknowledgment can repay or cancel them. Chapter II.-Of the Duties of Physicians to Each Other AND TO THE PROFESSION AT LARGE. ARTICLE I.-DUTIES FOR THE SUPPORT OF PROFESSIONAL CHARACTER. Section i.-Every individual on entering the profes- sion, as he becomes thereby entitled to all its privileges and immunities, incurs an obligation to exert his best abilities to maintain its dignity and honor, to exalt its standing, and to extend the bounds of its usefulness. He should, therefore, observe strictly such laws as are insti- tuted for the government of its members; should avoid all contumelious and sarcastic remarks relative to the faculty as a body; and while, by unwearied diligence, he resorts to every honorable means of enriching the science, he should entertain a due respect for his seniors, who have, by their labors, brought it to the elevated condition in which he finds it. Sec. 2.*-There is no profession from the members of * The following, which appears in the later publications of this system as Section 2, does not occur in the original document of 1847. It was added afterward by authority of the National Association. Sec. 2.-It is not in accord with the interests of the public or the honor of the profession that any physician or medical teacher 288 APPENDIX which greater purity of character and a higher standard of moral excellence are required, than the medical; and to attain such eminence is a duty every physician owes alike to his profession and to his patients. It is due to the latter, as yvithout it he can not command their respect and confidence, and to both, because no scientific attain- ments can compensate for the want of correct moral prin- ciples. It is also incumbent on the faculty to be temper- ate in all things, for the practice of physics requires the unremitting exercise of a clear and vigorous understand- ing; and in emergencies, for which no professional man should be unprepared, a steady hand, an acute eye and an unclouded head may be essential to the well-being, and even to the life, of a fellow-creature. Sec. 3.-It is derogatory to the dignity of the profes- sion to resort to public advertisements, or private cards, or handbills, inviting the attention of individuals affected with particular diseases-publicly offering advice and medicine to the poor gratis, or promising radical cures; or to publish cases and operations in the daily prints, or to suffer such publications to be made; to invite laymen to be present at operations; to boast of cures and remedies; to adduce certificates of skill and success, or to perform any other similar acts. These are the ordinary practices of empirics, and are highly reprehensible in a regular physician. should examine or sign diplomas or certificates of proficiency for, or otherwise be specially concerned with, the graduation of per- sons whom they have good reason to believe intend to support and practice any exclusive and irregular system of medicine. 289 MORAL PHILOSOPHY OF MEDICINE Sec. 4.-Equally derogatory to professional character is it for a physician to hold a patent for any surgical instru- ment or medicine, or to dispense a secret nostrum, whether it be the composition or exclusive property of himself or others. For, if such nostrum be of real effic.acy, any con- cealment regarding it is inconsistent with beneficence and professional liberality; and if mystery alone give it value and importance, such craft implies either disgraceful igno- rance or fraudulent avarice. It is also reprehensible for physicians to give certificates attesting the efficacy of patent or secret medicines, or in any way to promote the use of them. ARTICLE II.-PROFESSIONAL SERVICES OF PHYSICIANS TO EACH OTHER. Section i.-All practisers of medicine, their wives, and their children while under the paternal care, are en- titled to the gratuitous services of any one or more of the faculty residing near them, whose assistance may be desired. A physician afflicted with disease is usually an incompetent judge of his own case; and the natural anxiety and solicitude which he experiences at the sick- ness of a wife, a child, or any one who, by ties of consan- guinity, is rendered peculiarly dear to him, tend to obscure his judgment and produce timidity and irresolution in his practice. Under such circumstances medical men are peculiarly dependent upon each other, and kind offices and professional aid should always be cheerfully and gra- tuitously afforded. Visits ought not, however, to be ob- 290 APPENDIX truded officiously; as such unasked civility may give rise to embarrassment, or interfere with that choice on which confidence depends. But if a distant member of the fac- ulty, whose circumstances are affluent, requests attend- ance, and an honorarium be offered, it should not be declined; for no pecuniary obligation ought to be imposed, which the party receiving it would wish not to incur. ARTICLE III.-OF THE DUTIES OF PHYSICIANS AS RESPECTS VICARIOUS OFFICES Section i.-The affairs of life, the pursuit of health, and the various accidents and contingencies to which a medical man is peculiarly exposed, sometimes require him temporarily to withdraw from his duties to his patients, and to request some of his professional brethren to officiate for him. Compliance with this request is an act of courtesy which should always be performed with the utmost con- sideration for the interest and character of the family physician, and when exercised for a short period all the pecuniary obligations for such services should be awarded to him. But if a member of the profession neglect his business in quest of pleasure and amusement, he can not be considered as entitled to the advantages of the fre- quent and long-continued exercise of this fraternal courtesy without awarding to the physician who officiates the fees arising from the discharge of his professional duties. In obstetrical and important surgical cases, which give rise to unusual fatigue, anxiety and responsibility, it is 291 MORAL PHILOSOPHY OF MEDICINE just that the fees accruing therefrom should be awarded to the physician who officiates. ARTICLE IV.-OF THE DUTIES OF PHYSICIANS IN REGARD TO CONSULTATIONS Section i-A regular medical education furnishes the only presumptive evidence of professional abilities and acquirements, and ought to be the only acknowledged right of an individual to the exercise and honors of his profession. Nevertheless, as in consultations the good of the patient is the sole object in view, and this is often dependent on personal confidence, no intelligent regular practitioner, who has a license to practice from some medi- cal board of known and acknowledged respectability, recognized by the Association, and who is of good moral and professional standing in the place where he resides, should be fastidiously excluded from fellowship, or his aid refused in consultation, when it is requested by the patient. But no one can be considered as a regular physician or a fit associate in consultation whose practice is based on an exclusive dogma, to the rejection of the accumulated experience of the profession, and the aids actually fur- nished by anatomy, physiology, pathology and organic chemistry. Sec. 2.--In consultations, no rivalship or jealousy should be indulged; candor, probity and all due respect should be exercised toward the physician having charge of the case. Sec. 3.-In consultations the attending physician should be the first to propose the necessary questions to the 292 APPENDIX sick; after which the consulting physician should have the opportunity to make such further inquiries of the patient as may be necessary to satisfy him of the true character of the case. Both physicians should then retire to a private place for deliberation; and the one first in attendance should communicate the directions agreed upon to the patient or his friends, as well as any opinion which it may be thought proper to express. But no state- ment or discussion of it should take place before the pa- tient or his friends, except in the presence of all the faculty attending, and by their common consent; and no opinions or prognostications should be delivered which are not the result of previous deliberation and concurrence. Sec. 4.-In consultations, the physician in attendance should deliver his opinion first; and when there are sev- eral consulting, they should deliver their opinions in the order in which they have been called. No decision, how- ever, should restrain the attending physician from mak- ing such variations in the mode of treatment as any sub- sequent unexpected change in the character of the case may demand. But such variation, and the reasons for it, ought to be carefully detailed at the next meeting in consultation. The same privilege belongs also to the con- sulting physician if he is sent for in an emergency, when the regular attendant is out of the way, and similar ex- planation must be made by him at the next consultation. Sec. 5.-The utmost punctuality should be observed in the visits of physicians when they are to hold consulta- tions together, and this is generally practicable, for society 293 MORAL PHILOSOPHY OF MEDICINE has been considerate enough to allow the plea of a pro- fessional engagement to take precedence of all others, and to be an ample reason for the relinquishment of any pres- ent occupation. But as professional engagements may sometimes interfere and delay one of the parties, the phy- sician who first arrives should wait for his associate a rea- sonable period, after which the consultation should be considered as postponed to a new appointment. If it be the attending physician who is present, he will, of course, see the patient and prescribe; but if it be the consulting one, he should retire, except in case of emergency, or when he has been called from a considerable distance, in which latter case he may examine the patient, and give his opinion in writing and under seal, to be delivered to his associate. Sec. 6.-In consultations, theoretical discussions should be avoided, as occasioning perplexity and loss of time. For there may be much diversity of opinion concerning speculative points, with perfect agreement in those modes of practice which are founded, not on hypothesis, but on experience and observation. Sec. 7.-All discussions in consultation should be held as secret and confidential. Neither by words nor manner should any of the parties to a consultation assert or insin- uate that any part of the treatment pursued did not receive his assent. The responsibility must be equally divided between the medical attendants-they must equally share the credit of success as well as the blame of failure. 294 APPENDIX Sec. 8.-Should an irreconcilable diversity of opinion occur when several physicians are called upon to consult together, the opinion of the majority should be considered as decisive; but if the numbers be equal on each side, then the decision should rest with the attending physician. It may, moreover, sometimes happen that two physicians cannot agree in their views of the nature of a case and the treatment to be pursued. This is a circumstance much to be deplored, and should always be avoided, if possible, by mutual concessions, as far as they can be justified by a conscientious regard for the dictates of judgment. But in the event of its occurrence, a third physician should, if practicable, be called to act as umpire; and, if circum- stances prevent the adoption of this course, it must be left to the patient to select the physician in whom he is most willing to confide. But, as every physician relies upon the rectitude of his judgment, he should, when left in the minority, politely and consistently retire from any further deliberation in the consultation, or participation in the management of the case. Sec. 9.-As circumstances sometimes occur to render a special consultation desirable, when the continued attend- ance of two physicians might be objectionable to the patient, the member of the faculty whose assistance is required in such cases should sedulously guard against all future unsolicited attendance. As such consultations re- quire an extraordinary portion of both time and attention, at least a double honorarium may be reasonably expected. Sec. io.-A physician who is called upon to consult, 295 MORAL PHILOSOPHY OF MEDICINE should observe the most honorable and scrupulous regard for the character and standing of the physician in attend- ance; the practice of the latter, if necessary, should be justified as far as can be, consistently with a conscientious regard for truth, and no hint or insinuations should be thrown out which could impair the confidence reposed in him, or affect his reputation. The consulting physician should also carefully refrain from any of those extraordi- nary attentions or assiduities which are too often prac- ticed by the dishonest for the base purpose of gaining applause, or ingratiating themselves into the favor of families and individuals. ARTICLE V.-DUTIES OF PHYSICIANS IN CASES OF INTERFERENCE Section i.-Medicine is a liberal profession, and those admitted into its ranks should found their expectations of practice upon the extent of their qualifications; not on intrigue or artifice. Sec. 2.-A physician, in his intercourse with a patient under the care of another physician, should observe the strictest caution and reserve. No meddling inquiries should be made-no disingenuous hints given relative to the nature and treatment of his disorder; nor any course of conduct pursued that may directly or indirectly tend to diminish the trust reposed in the physician employed. Sec. 3.-The same circumspection and reserve should be observed when, from motives of business or friendship, a physician is prompted to visit an individual who is under the direction of another physician. Indeed, such 296 APPENDIX visits should be avoided, except under peculiar circum- stances; and when they are made, no particular inquiries should be instituted relative to the nature of the disease, or the remedies employed, but the topics of conversation should be as foreign to the case as circumstances will admit. Sec. 4.-A physician ought not to take charge of or prescribe for a patient who has recently been under the care of another member of the faculty in the same illness, except in cases of sudden emergency, or in consultation with the physician previously in attendance, or when the latter has relinquished the case, or been regularly notified, that his services are no longer desired. Under such cir- cumstances, no unjust and illiberal insinuations should be thrown out in relation to the conduct or practice previously pursued, which should be justified as far as candor and regard for truth and probity will permit; for it often hap- pens that patients become dissatisfied when they do not experience immediate relief, and, as many diseases are naturally protracted, the want of success, in the first stage of treatment, affords no evidence of a lack of professional knowledge and skill. Sec. 5.-When a physician is called to an urgent case, because the family attendant is not at hand, he ought, unless his assistance in consultation be desired, to resign the care of the patient to the latter immediately on his arrival. Sec. 6.-It often happens in case of sudden illness, or of recent accidents and injuries, owing to the alarm and 297 MORAL PHILOSOPHY OF MEDICINE anxiety of friends, that a number of physicians are simul- taneously sent for. Under these circumstances, courtesy should assign the patient to the first who arrives, who should select from those present any additional assistance that he may deem necessary. In all such cases, however, the physician who officiates should request the family physician, if there be one, to be called, and, unless his further attendance be requested, should resign the case to the latter on his arrival. Sec. 7.--When a physician is called to the patient of another physician, in consequence of the sickness or absence of the latter, he ought on the return or recovery of the regular attendant and with the consent of the patient to surrender the case. The expression "patient of another physician," is understood to mean a patient who may have been under the charge of another physician at the time of the attack of sickness or departure from home of the latter, or who may have called for his attendance during his absence or sickness, or in any other manner given it to be understood that he regarded the said physician as his regular medical attendant. Sec. 8.-A physician, when visiting a sick person in the country, may be desired to see a neighboring patient who is under the regular direction of another physician, in con- sequence of some sudden change or aggravation of symp- toms. The conduct to be pursued on such an occasion is to give advice adapted to present circumstances; to inter- fere no further than is absolutely necessary with the gen- 298 APPENDIX eral plan of treatment; to assume no future direction unless it be expressly desired; and, in this last case, to request an immediate consultation with the physician previously employed. Sec. 9.-A wealthy physician should not give advice gratis to the affluent; because his doing so is an injury to his professional brethren. The office of a physician can never be supported as an exclusively beneficent one; and it is defrauding, in some degree, the common funds for its support, when fees are dispensed with which might justly be claimed. Sec. io.-When a physician who has been engaged to attend a case of midwifery is absent, another is sent for; if delivery is accomplished during the attendance of the latter, he is entitled to fee, but should resign the patient to the physician first engaged. ARTICLE VI.-OF DIFFERENCES BETWEEN PHYSICIANS Section i.-Diversity of opinion and opposition of interest may, in the medical as in other professions, some- times occasion controversy and even contention. When- ever such cases unfortunately occur and cannot be immedi- ately terminated, they should be referred to the arbitration of a sufficient number of physicians or a court-medical. Sec. 2.-As peculiar reserve must be maintained by physicians toward the public, in regard to professional matters, and as there exist numerous points in medical morals and etiquette through which the feelings of medical men may be painfully assailed in their intercourse with 299 MORAL PHILOSOPHY OF MEDICINE each other, and which can not be understood or appreciated by general society, neither the subject-matter of such dif- ferences nor the adjudication of the arbitrators should be made public, as publicity in a case of this nature may be personally injurious to the individuals concerned, and can hardly fail to bring discredit on the faculty. Some general rules should be adopted by the faculty, in every town or district, relative to pecuniary acknowl- edgments from their patients; and it should be deemed a point of honor to adhere to these rules with as much uni- formity as varying circumstances will admit. ARTICLE VII.-OF PECUNIARY ACKNOWLEDGMENT Chapter III.-Of the Duties of the Profession to the Pub- lic, and of the Obligations of the Public to the Profession ARTICLE I.-DUTIES OF THE PROFESSION TO THE PUBLIC Section i.-As good citizens, it is the duty of physi- cians to be very vigilant for the welfare of the community, and to bear their part in sustaining its institutions and burdens; they should also be ever ready to give counsel to the public in relation to matters especially appertaining to their profession, as on subjects of medical police, public hygiene and legal medicine. It is their province to en- lighten the public in regard to quarantine regulations; the location, arrangement and dietaries of hospitals, asylums, schools, prisons, and similar institutions; in relation to the medical police of towns, as drainage, ventilation, etc.; 300 APPENDIX and in regard to measures for the prevention of epidemic and contagious diseases; and when pestilence prevails, it is their duty to face the danger, and to continue their labors for the alleviation of the suffering, even at the jeopardy of their own lives. Sec. 2.-Medical men should also be always ready, when called on by the legally constituted authorities, to en- lighten coroners' inquests and courts of justice on subject strictly medical-such as involve questions relating to sanity, legitimacy, murder by poison or other violent means, and in regard to the various other subjects em- braced in the science of Medical Jurisprudence. But in these cases, and especially where they are required to make a post-mortem examination, it is just, in consequence of the time, labor and skill required, and the responsibility and risk they incur, that the public should award them a proper honorarium. Sec. 3.-There is no profession by the members of which eleemosynary services are more liberally dispensed than the medical, but justice requires that some limits should be placed to the performance of such good offices. Pov- erty, professional brotherhood, and certain of the public duties referred to in the first section of this article, should always be recognized as presenting valid claims for gra- tuitous services; but neither institutions endowed by the public or by rich individuals, societies for mutual benefit, for the insurance of lives or for analogous purposes, nor any profession or occupation, can be admitted to possess such privilege. Nor can it be justly expected of physicians to 301 MORAL PHILOSOPHY OF MEDICINE furnish certificates of inability to serve on juries, to per- form militia duty, or to testify to the state of health of persons wishing to insure their lives, obtain pensions, or the like, without a pecuniary acknowledgment. But to individuals in indigent circumstances, such professional services should always be cheerfully and freely accorded. Sec. 4.-It is the duty of physicians, who are frequent witnesses of the enormities committed by quackery, and the injury to health and even destruction of life caused by the use of quack medicines, to enlighten the public on these subjects, to expose the injuries sustained by the unwary from the devices and pretensions of artful empirics and impostors. Physicians ought to use all the influence which they may possess, as professors in Colleges of Phar- macy, and by exercising their option in regard to the shops to which their prescriptions shall be sent, to discourage druggists and apothecaries from vending quack or secret medicines, or from being in any way engaged in their manufacture and sale. ARTICLE II.-OBLIGATIONS OF THE PUBLIC TO PHYSICIANS. Section i .-The benefits accruing to the public, directly and indirectly, from the active and unwearied beneficiaries of the profession, are so numerous and important that physicians are justly entitled to the utmost consideration and respect from the community. The public ought like- wise to entertain a just appreciation of medical qualifica- tions; to make a proper discrimination between true sci- ence and the assumptions of ignorance and empiricism; 302 APPENDIX to afford every encouragement and facility for the acquisi- tion of medical education-and no longer to allow the statute books to exhibit the anomaly of exacting knowl- edge from physicians, under a liability to heavy penalties, and of making them obnoxious to punishment for resort- ing to the only means of obtaining it. 303 Ill REMARKS ON THE NATIONAL SYSTEM One perusal is scarcely sufficient, even to the most atten- tive reader, for mentally grasping and fully appreciating all of the many wise and salutary provisions of this com- prehensive system of medical morals. It should be scrutinised chapter by chapter, article by article, section by section, sentence by sentence, so that the student can eventually create in his mind an index including all the parts and phrases to which he may have to refer. Notwithstanding the excellence of this system of morals, it has been vehemently opposed by certain physicians; some of their specious allegations being that it is "an encroachment on their rights as citizens; that they wished to free themselves from its bondage which had held them in the most degrading subjection-a kind of moral slavery -and that their struggle was for liberty, etc " It was suggested by a contemporary writer that such "struggle" seemed more like a struggle for licence than liberty, for, the National system of morals advocates unlimited liberty to do good, while it grants no licence to evil doers. They further sophistically alleged that the provisions of the system being so frequently violated, the 304 APPENDIX document must be regarded as a dead letter and forth- with revoked. When asked if a repeatedly broken criminal law should be regarded as a dead letter because so many guilty culprits escape punishment, and if the ten com- mandments should be regarded as obsolete because so often disregarded? They shirked a categoric answer and made none other than that the American system provides for no punishment to its violators and that, therefore, it is not necessary; nor did they take heed of the dictum that "there is no punishment connected with violations of the laws of medicine except sting of conscience and disgrace." Although these laws cannot change the nature of followers of Belial, they warn others to avoid evil and to shun wrong doers, and point out the right path which is not always easily found by the inexperienced howsoever earnestly they may seek it. This National System of morals has been qualified, by other objectors, as ideal, not penal, as if penal were logi- cally opposed to ideal or, with any propriety, could be used in contra-distinction. Of course, they would like it to be ideal, that is to say, non-existant except in the mind; whereas it is real, penal, and its penalties are as evident as are those for violation of any law of nature. It is apparent that those who entertained the notion of an ideal system of morals did not realise that they were using the terms ideal and penal without thinking seriously of the significance of these two words. Had they reflected a moment, they probably would have remembered the saying of the sage who spoke of the ideal as "that which 305 MORAL PHILOSOPHY OF MEDICINE the mind contemplates as a representative of excellence . . . . the prototype of all things .... though it is impossible that they can ever attain perfection; and that the image is the work while the idea (the thought) is before the work." Had they given mature consideration to the subject they surely would have regarded all the laws, all the works of men as first ideal; being real only when expressed, when performed; the idea, coming first, is elaborated in the mind and afterward set forth in writing or in speech, or given form by the hand, then and then only it is real. They would have believed that a penal system of rules and all law maxims were ideal when con- ceived in the mind, and became real as soon as expressed; that the adjective ideal is applicable here only to qualify what dwells in the mind and remains unexpressed, and can not be used to qualify a written or printed document or any spoken words; that all ideal laws and moral max- ims, as soon as authoritatively expressed become real and penal; that some sort of penalty necessarily follows the violation of every law whatsoever; that all laws command or imply thou shalt or thou shalt not; that the penalty is generally proportionate to the kind or degree of viola- tion; that the penalty may be imposed by a judge, by the violator himself perhaps in his own conscience, or by nature; that the penalties for some crimes are defined by statute law, but the degree of violation is often deter- minable by the court; that violations of laws governing the social or business relations of men, not criminal vio- lations, are punished by adjudgment of the damages 306 APPENDIX awarded to the injured individual; that, for violations known to the violator only, the penalty is sting of con- science and loss of self-respect; that when fire is applied to his own body by a man, the penalty for this violation of a law of nature is pain and a more or less severe burn -even in this case the penalty is proportionate to the degree of violation. Hence criminal, civil, and moral laws are all ideal when conceived in the mind, and become real and penal when authoritatively expressed. Many of those physicians who wished the abolition of this system of morals acknowledged that they had never read it and declared that they did not care ever to do so. To loyal members of the profession it is truly shocking that thinking beings should be so ready, without examina- tion, to deny the necessity of, and to condemn, this or any other system of morals despite the well-known fact that there is no profession or association of men that does not demand to be governed by some system of rules of conduct. Later captious critics striving to discover, in the National System, something to traverse, and failing to find any flaw in its maxims, fall back on the weak censure of its style as "quaint and exuberant,'' without taking note of any pos- sible verbal or phrasic defects, for they well know that there are so few writings in which some imperfections, however little, may not be detected. But the very slight literary blemishes of this great moral production do not mar in the least degree its salutary teachings of which no fair-minded reader will find anything to gainsay. 307 IV THE EXPLANATORY DECLARATIONS The wail for abolition was so incessant, among the dis- affected whose unreasonable objection to the first section of the fourth article, of the second chapter as to lead the National Association to appoint a committee charged with the interpretation of that first section decried, chiefly and most loudly, by those who boasted of never having read it. The committee's report was adopted in 1885, in the form of a preamble and resolutions to which was given the title of Explanatory Declarations, in substance as follows: Whereas, Persistent misrepresentations have been and still are made concerning certain provisions of the System of Morals of this Association, by which many in the community, and some in the ranks of the profession, are led to believe those provisions exclude persons from professional recognition simply because of differences of opinions or doctrines; therefore, i. Resolved, That clause first, of Art. IV, in the National Sys- tem of Medical Morals, is not to be interpreted as excluding from professional fellowship, on the ground of differences in doctrine or belief, those who in other respects are entitled to be members of the regular medical profession. Neither is there any other article or clause of the said System of Morals that interferes with the exercise of the most perfect liberty of individual opinion and practice. 2. Resolved, That it constitutes a voluntary disconnection or withdrawal from the medical profession proper, to assume a 308 APPENDIX name indicating to the public a sectarian, or exclusive system of practice, or to belong to an association or party antagonistic to the general medical profession. 3. Resolved, That there is no provision in the National Sys- tem of Medical Morals in any wise inconsistent with the broadest dictates of humanity, and that the article of the System which relates to consultations cannot be correctly interpreted as inter- dicting, under any circumstances, the rendering of professional services whenever there is a pressing or immediate need of them On the contrary, to meet the emergencies occasioned by disease or accident, and to give a helping hand to the distressed without unnecessary delay, is a duty fully enjoined on every member of the profession, both by the letter and the spirit of the entire System. But no such emergencies or circumstances can make it necessary or proper to enter into formal professional con- sultations with those who have voluntarily disconnected themselves from the regular medical profession, in the manner indicated by the preceding resolution. N. S. Davis of Chicago. A. Y. P. Garnett of Washington. H. F. Campbell of Augusta, Ga. Austin Flint of New York. J. B. Murdock of Pittsburg. On motion of Dr. Brodie the resolutions were unani- mously adopted. On motion of Dr. Keller, it was unanimously agreed that the resolutions be placed as an explanatory adden- dum in all future publications of the System. 309 V REMARKS ON THE EXPLANATORY DECLARATIONS That these declarations were called for is evidenced in their preamble. However, as the super-censorious spirit dwells in many, the objectors are not few and are ever ready to traverse almost anything; so they disapprove of the adjective explanatory as a qualifier of the declara- tions; their chief ground of objection being that a thing requiring explanation can not be good, so, according to this sophism nothing is good here below, for every ter- restrial thing requires definition which is a condensed explanation. Assuredly there are many good things on this earth, and one of them is this very system of morals which is so conducive to good actions, and which, in part at least, has been so sorely assailed and misinterpreted as to require definition. The physician who inspired these declarations used the following precedent to justify his views, and said that certain doctrines of the church were never defined until they were attacked; then the definition made was irrevokable. ■ A certain part of this system of morals having been attacked called for the able definition which was made. A definition being a concise 310 APPENDIX explanation, the adjective explanatory was suitable and proper to the case. These liberal Explanatory Declarations failed entirely to appease the wrath of the disaffected who have never ceased their unbecoming agitation. 311 f VI THE ABSTRACT OF THE NATIONAL SYSTEM During the period between the years 1890 and 1901, the demand having been made so repeatedly by a new crop of malcontents, for "abbreviation" of the system of 1847, the New York State Medical Association offered to the National Association, in the year 1902, a carefully prepared abstract of the system of laws of 1847, which was adopted in 1903, after having been shorn of some of its most important provisions, and after the addition of two sections on organization whose place in a system of morals is questionable. With some other additions whose necessity is not apparent, that abstract of the National system of laws was given out only "as a suggestive and advisory document." So the true student of medical morals will always have to go back to the original system of 1847 for such information as is not contained in the abstract, In the preface to this abstract it is distinctly stated that all local societies may establish their own rules of conduct provided they do not interfere with the prin- ciples of the National Association. It is therefore fair to conclude that any of these societies may adopt the whole system of 1847 if so disposed. The modified abstract is as follows: 312 APPENDIX The American Medical Association promulgates as a suggestive and advisory document the following: Chapter I.,-The Duties of Physicians to their Patients Section i.--Physicians should not only be ever ready to obey the calls of the sick and the injured, but should be mindful of the high character of their mission and of the responsibilities they must incur in the discharge of momentous duties. In their ministrations they should never forget that the comfort, the health, and the lives of those entrusted to their care depend on skill, attention and fidelity. In deportment they should unite tenderness, cheerfulness and firmness, and thus inspire all sufferers with gratitude, respect and confidence. These observances are the more sacred because, generally, the only tribunal to adjudge penalties for unkindness, carelessness or neglect is their own conscience. Sec. 2.-Every patient committed to the charge of a physician should be treated with attention and humanity, and reasonable indulgence should be granted to the caprices of the sick. Secrecy and delicacy should be strictly observed; and the familiar and confidential inter- course to which physicians are admitted, in their profes- sional visits, should be guarded with the most scrupulous fidelity and honor. Sec. 3.-The obligation of secrecy extends beyond the period of professional services; none of the privacies of individual or domestic life, no infirmity of disposition or 313 MORAL PHILOSOPHY OF MEDICINE flaw of character observed during medical attendance, should ever be divulged by physicians, except when imperatively required by the laws of the state. The force of the obligation of secrecy is so great that physicians have been protected in its observance by courts of justice. Sec. 4.-Frequent visits to the sick are often requisite, since they enable the physician to arrive at a more perfect knowledge of the disease, and to meet promptly every change which may occur. Unnecessary visits are to be avoided, as they give undue anxiety to the patient; but to secure the patient against irritating suspense and dis- appointment the regular and periodical visits of the physician should be made as nearly as possible at the hour when they may be reasonably expected by the patient. Sec. 5.-Ordinarily, the physician should not be for- ward to make gloomy prognostications, but should not fail, on proper occasions, to give timely notice of danger- ous manifestations to the friends of the patient; and even to the patient, if absolutely necessary. This notice, how- ever, is at times so peculiarly alarming when given by the physician, that its deliverance may often be preferably assigned to another person of good judgment. Sec. 6.-The physician should be a minister of hope and comfort to the sick, since life may be lengthened or short- ened not only by the acts but by the words or manner of the physician, whose solemn duty is to avoid all utterances and actions having a tendency to discourage and depress the patient. 314 APPENDIX Sec. 7.-The medical attendant ought not to abandon a patient because deemed incurable; for continued atten- tion may be highly useful to the sufferer and comforting to the relatives, even in the last period of the fatal malady, by alleviating pain and by soothing mental anguish. Sec. 8.-The opportunity which a physician has of pro- moting and strengthening the good resolutions of patients suffering under the consequences of evil conduct ought never to be neglected. Good counsels, or even remon- strances, will give satisfaction, not offense, if they be tact- fully proffered and evince a genuine love of virtue, accom- panied by a sincere interest in the welfare of the person to whom they are addressed. Chapter II.-The Duties of Physicians to Each Other and to the Profession at Large. ARTICLE I.-DUTIES FOR THE SUPPORT OF PROFESSIONAL CHARACTER. Section i.-Every one on entering the profession, and thereby becoming entitled to full professional fellowship, incurs an obligation to uphold its dignity and honor, to exalt its standing and to extend the bounds of its useful- ness. It is inconsistent with the principles of medical science and it is incompatible with honorable standing in the profession for physicians to designate their practice as based on an exclusive dogma or a sectarian system of medicine. Sec. 2.-The physician should observe strictly such laws as are instituted for the government of the members 315 MORAL PHILOSOPHY OF MEDICINE of the profession; should honor the fraternity as a body; should endeavor to promote the science and art of medi- cine and should entertain a due respect for those seniors who, by their labors, have contributed to its advance- ment. Sec. 3.-Every physician should identify himself with the organized body of his profession as represented in the community in which he resides. The organization of local or county medical societies, where they do not exist, should be effected, so far as practicable. Such county societies, constituting as they do the chief element of strength in the organization of the profession, should have the active support of their members and should be made instruments for the cultivation of fellowship, for the ex- change of professional experience, for the advancement of medical knowledge, for the maintenance of ethical stand- ards, and for the promotion in general of the interests of the profession and the welfare of the public. Sec. 4.-All county medical societies thus organized ought to place themselves in affiliation with their respec- tive state associations, and these, in turn, with the Amer- ican Medical Association. Sec. 5.-There is no profession from the members of which greater purity of character and a higher standard of moral excellence are required than the medical; and to attain such eminence is a duty every physician owes alike to the profession and to patients. It is due to the patients, as without it their respect and confidence cannot be com- manded; and to the profession, because no scientific 316 APPENDIX attainments can compensate for the want of correct moral principles. Sec. 6.-It is incumbent on physicians to be temperate in all things, for the practice of medicine requires the unremitting exercise of a clear and vigorous understanding; and in emergencies-for which no physician should be unprepared-a steady hand, an acute eye and an unclouded mind are essential to the welfare and even to the life of a human being. Sec. 7.-It is incompatible with honorable standing in the profession to resort to public advertisement or private cards inviting the attention of persons affected with par- ticular diseases; to promise radical cures; to publish cases or operations in the daily prints, or to suffer such publica- tions to be made; to invite laymen (other than relatives who may desire to be at hand) to be present at operations; to boast of cures and remedies; to adduce certificates of skill and success, or to employ any of the other methods of charlatans. Sec. 8.-It is equally derogatory to professional char- acter for physicians to hold patents for any surgical instru- ments or medicines; to accept rebates on prescriptions or surgical appliances; to assist unqualified persons to evade the legal restrictions governing the practice of medicine; or to dispense, or promote the use of, secret medicines, for if such nostrums are of real efficacy, any concealment regarding them is inconsistent with beneficence and pro- fessional liberality, and if mystery alone give them public notoriety, such craft implies either disgraceful ignorance 317 MORAL PHILOSOPHY OF MEDICINE or fraudulent avarice. It is highly reprehensible for phy- sicians to give certificates attesting the efficacy of secret medicines, or other substances used therapeutically. ARTICLE II.-PROFESSIONAL SERVICES OF PHYSICIANS TO EACH OTHER Section i.-Physicians should not, as a general rule, undertake the treatment of themselves, nor of members of their family. In such circumstances they are peculiarly dependent on each other; therefore, kind offices and pro- fessional aid should always be cheerfully and gratuitously afforded. ' These visits ought not, however, to be obtru- sively made, as they may give rise to embarrassment or interfere with that free choice on which such confidence depends. Sec. 2.-All practicing physicians and their immediate family dependants are entitled to the gratuitous services of any one or more of the physicians residing near them. Sec. 3.-When a physician is summoned from a dis- tance to the bedside of a colleague in easy financial cir- cumstances, a compensation, proportionate to traveling expenses and to the pecuniary loss entailed by absence from the accustomed field of professional labor, should be made by the patient or relatives. Sec. 4.-When more than one physician is attending another, one of the number should take charge of the case, otherwise the concert of thought and action so essential to wise treatment can not be assured. 318 APPENDIX Sec. 5.-The affairs of life, the pursuit of health and thewarious accidents and contingencies to which a phy- sician is peculiarly exposed sometimes require the tempo- rary withdrawal of this physician from daily professional labor and the appointment of a colleague to act for a: specified time. The colleague's compliance is an act of courtesy which should always be performed with the ut- most consideration fof the interest and character of the family physician. ARTICLE III.-THE DUTIES OF PHYSICIANS IN REGARD TO CONSULTATIONS Section i.-The broadest dictates of humanity should be obeyed by physicians whenever and wherever their services are needed to meet the emergencies of disease or accident. Sec. 2.-Consultations should be promoted in difficult cases, as they contribute to confidence and more enlarged views of practice. Sec. 3.-The utmost punctuality should be observed in the visits of physicians when they are to hold consulta- tions, and this is generally practicable, for society has been so considerate as to allow the plea for a professional engagement to take precedence over all others. Sec. 4.-As professional engagements may sometimes cause delay in attendance, the physician who first arrives should wait for a reasonable time, after which the consul- tation should be considered as postponed to a new ap- pointment. 319 MORAL PHILOSOPHY OF MEDICINE Sec. 5.-In consultations no insincerity, rivalry or envy should be indulged; candor, probity and all due respect should be observed toward the physician in charge of the case. Sec. 6.-No statement or discussion of the case should take place before the patient or friends, except in the presence of all the physicians attending, or by their com- mon consent; and no opinions or prognostications should be delivered which are not the result of previous delibera- tion and concurrence. Sec. 7.-No decision should restrain the attending phy- sician from making such subsequent variations in the mode of treatment as any unexpected change in the character of the case may demand. But at the next consultation reasons for the variations should be stated. The same privilege, with its obligation, belongs to the consultant when sent for in an emergency during the absence of the family physician. Sec. 8.-The attending physician, at any time, may prescribe for the patient; not so the consultant, when alone, except in a case of emergency or when called from a considerable distance. In the first instance the consult- ant should do what is needed, and in the second should do no more than make an examination of the patient and leave a written opinion, under seal, to be delivered to the attending physician. Sec. 9.-All discussions in consultation should be held as confidential. Neither by words nor by manner should any of the participants in a consultation assert or intimate 320 APPENDIX that any part of the treatment pursued did not receive his assent. Sec. io.-It may happen that two physicians can not agree in their views of the nature of a case and of the treatment to be pursued. In the event of such disagree- ment a third physician should, if practicable, be called in. None but the rarest and most exceptional circumstances would justify the consultant in taking charge of the case. He should not do so merely on the solicitation of the patient or friends. Sec. ii.-A physician who is called in consultation should observe the most honorable and scrupulous regard for the character and standing of the attending physician, whose conduct of the case should be justified, as far as can be, consistently with a conscientious regard for truth, and no hint or insinuation should be thrown out which would impair the confidence reposed in the attending physician. ARTICLE IV.-DUTIES OF PHYSICIANS IN CASES OF INTERFERENCE Section i.-Medicine being a liberal profession, those admitted to its ranks should found their expectations of practice especially on the character and the extent of their medical education. Sec. 2.-The physician, in his intercourse with a patient under the care of another physician, should observe the strictest caution and reserve; should give no disingenuous hints relative to the nature and treatment of the patient's disorder, nor should the course of conduct of the physi- 321 MORAL PHILOSOPHY OF MEDICINE cian, directly or indirectly, tend to diminish the trust reposed in the attending physician. Sec. 3.-The same circumspection should be observed when, from motives of business or friendship, a physician is prompted to visit a person who is under the direction of another physician. Indeed, such visits should be avoided, except under peculiar circumstances; and when they are made, no inquiries should be instituted relative to the nature of the disease, or the remedies employed, but the topics of conversation should be as foreign to the case as circumstances will admit. Sec. 4.-A physician ought not to take charge of, or prescribe for, a patient who has recently been under the care of another physician, in the same illness, except in case of a sudden emergency, or in consultation with the physician previously in attendance, or when that physi- cian has relinquished the case or has been dismissed in due form. Sec. 5.-The physician acting in conformity with the preceding section should not make damaging insinuations regarding the practice previously adopted, and, indeed, should justify it if consistent with truth and probity; for it often happens that patients become dissatisfied when they are not immediately relieved, and, as many diseases are naturally protracted, the seeming want of success, in the first stage of treatment, affords no evidence of a lack of professional knowledge or skill. Sec. 6.-When a physician is called to an urgent case, because the family attendant is not at hand, unless assist- 322 APPENDIX ance in consultation is desired, the former should resign the care of the patient immediately on the arrival of the family physician. Sec. 7.-It often happens, in cases of sudden illness, and of accidents and injuries, owing to the alarm and anxiety of friends, that several physicians are simultane- ously summoned. Under these circumstances, courtesy should assign the patient to the first who arrives, and who, if necessary, may invoke the aid of some of those present. In such case, however, the acting physician should request that the family physician be called, and should withdraw unless requested to continue in attendance. Sec. 8.-Whenever a physician is called to the patient of another physician during the enforced absence of that physician the case should be relinquished on the return of the latter. Sec. 9.-A physician, while visiting a sick person in the country, may be asked to see another physician's patient because of a sudden aggravation of the disease. On such an occasion the immediate needs of the patient should be attended to and the case relinquished on the arrival of the attending physician. Sec. io.-When a physician who has been engaged to attend an obstetric case is absent and another is sent for, delivery being accomplished during the vicarious attend- ance, the acting physician is entitled to the professional fee, but must resign the patient on the arrival of the phy- sician first engaged. 323 MORAL PHILOSOPHY OF MEDICINE ARTICLE V.-DIFFERENCES BETWEEN PHYSICIANS Section i.-Diversity of opinion and opposition of in- terest may, in the medical as in other professions, some- times occasion controversy and even contention. When- ever such unfortunate cases occur and cannot be immedi- ately adjusted, they should be referred to the arbitration of a sufficient number of impartial physicians. Sec. 2.-A peculiar reserve must be maintained by phy- sicians toward the public in regard to some professional questions, and as there exist many points in medical ethics and etiquette through which the feelings of physicians may be painfully assailed in their intercourse, and which can not be understood or appreciated by general society, neither the subject-matter of their differences nor the adjudica- tion of the arbitrators should be made public. ARTICLE VI. COMPENSATION Section i.-By the members of no profession are eleemosynary services more liberally dispensed than by the medical, but justice requires that some limits should be placed to their performance. Poverty, mutual pro- fessional obligations, and certain of the public duties named in Sections i and 2, of Chapter HI, should always be recognized as presenting valid claims for gratuitous services; but neither institutions endowed by the public or by the rich, or by societies for mutual benefit, for life insurance, or for analogous purposes, nor any profession or occupation, can be admitted to possess such privilege. 324 APPENDIX Sec. 2.-It cannot be justly expected of physicians, to furnish certificates of inability to serve on juries, or to perform militia duty; to testify to the state of health of persons wishing to insure their lives, obtain pensions, or the like, without due compensation. But to persons in indigent circumstances such services should always be cheerfully and freely accorded. Sec. 3.-Some general rules should be adopted by the physicians in every town or district relative to the mini- mum pecuniary acknowledgment from their patients; and it should be deemed a point of honor to adhere to these rules with as much uniformity as varying circumstances will admit. Sec. 4.-It is derogatory to professional character for physicians to pay or offer to pay commissions to any per- son whatsoever who may recommend to them patients requiring general or special treatment or surgical opera- tions. It is equally derogatory to professional character for physicians to solicit or to receive such commissions. Chapter III.-The Duties of the Profession to the Public Section i.-As good citizens it is the duty of physicians to be very vigilant for the welfare of the community, and to bear their part in sustaining its laws, institutions and burdens; especially should they be ready to cooperate with the proper authorities in the administration and the observance of sanitary laws and regulations, and they should also be ever ready to give counsel to the public in relation to subjects especially appertaining to their pro- 325 MORAL PHILOSOPHY OF MEDICINE fession, as on questions of sanitary police, public hygiene and legal medicine. Sec. 2.-It is the province of physicians to enlighten the public in regard to quarantine regulations; to the lo- cation, arrangement and dietaries of hospitals, asylums, schools, prisons and similar institutions; in regard to measures for the prevention of epidemic and contagious diseases; and when pestilence prevails, it is their duty to face the danger, and to continue their labors for the alleviation of the suffering people, even at the risk of their own lives. Sec. 3.-Physicians, when called on by legally con- stituted authorities, should always be ready to enlighten inquests and courts of justice on subjects strictly medical, such as involve questions relating to sanity, legitimacy, murder by poison or other violent means, and various subjects embraced in the science of medical jurisprudence. It is but just, however,for them to expect duecompensation for their services. Sec. 4.-It is the duty of physicians, who are frequent witnesses of the great wrongs committed by charlatans, and of the injury to health and even destruction of life caused by the use of their treatment, to enlighten the public on these subjects, and to make known the injuries sustained by the unwary from the devices and pretensions of.artful impostors. Sec. 5.-It is the duty of physicians to recognize and by legitimate patronage to promote the profession of phar- macy, on the skill and proficiency of which depends the 326 APPENDIX reliability of remedies, but any pharmacist who, although educated in his own profession, is not a qualified physician, and who assumes to prescribe for the sick, ought not to receive such countenance and support. Any druggist or pharmacist who dispenses deteriorated or sophisticated drugs or who substitutes one remedy for another designated in a prescription ought thereby to forfeit the recognition and influence of physicians. 327 VII REMARKS ON THE ABSTRACT This document, though offered as "suggestive and ad- visory," is, in reality, a system of laws commanding that "physicians should" -not might-obey, etc., "should never forget," etc., etc. Indeed the imperative spirit per- vades nearly all the sections of the three chapters of this "suggestive and advisory" production which does not suggest but very decidedly orders what the duties of phy- sicians should be. This wrong title will be apparent to the most casual reader. Some of the omissions are unwise, unjust, and unpar- donable. Among them, the blotting out of the second article of the first chapter of the original, relating to the obligations of patients to their physicians; and the sec- ond article of the third chapter, on the obligations of the public to physicians. The framers of the document of 1847, inspired with the idea that there could be no justice, no mercy, no comity without reciprocity, which is the parent of good actions, had wisely introduced these two articles to impress upon the reader's mind that the obliga- tions of patient and physician must *be mutual, and that those of the public and the physician must also be mutual; 328 APPENDIX therefore neither the public nor patients should be kept in ignorance of the nature of these reciprocal obligations which they have every right to know. The "suggestive and advisory document" contains cer- tain additions which have no legitimate place in any sys- tem of medical morals; such as sections three and four in the first article of the second chapter. These sections relate to the organization of medical societies and are surely incongruous in a system of morals. The fourth section of the first article of the second chap- ter of the original appears in the abstract as its eighth sec- tion and contains some underscored additions and alter- ations that call for its reproduction at this particular place. These additions and alterations are not necessary because the right interpretation of the spirit of the original covers the ground. "It is equally derogatory to professional character for physicians to hold patents for any surgical instruments or medicines; to accept rebates on prescriptions or surgical appliances; to assist unqualified persons to evade the legal restrictions governing the practice of medicine; or to dis- pense, or promote the use of secret medicines, for if such nostrums are of real efficacy, any concealment regarding them is inconsistent with beneficence and professional liberality, and if mystery alone give them public notoriety, such craft implies either disgraceful ignorance or fraudu- lent avarice. It is highly reprehensible for physicians to give certificates attesting the efficacy of secret medicines, or other substances used therapeutically." 329 MORAL PHILOSOPHY OF MEDICINE Of the first sentence of the original section four, Doctor Flint says in his commentaries: "The grounds for the injunction not to patent remedies or surgical instruments, and not to dispense secret nos- trums, are not always appreciated by the public. Some appear to think that it is dictated by jealousy or profes- sional prejudice. The reasons are concisely but clearly stated in the National System. Imagine Jenner to have applied for a patent giving exclusive property to vaccina- tion, or keeping it a secret! How different would the names of those identified with the discovery and introduc- tion of anaesthesia in surgical and medical practice appear in history, had the attempt not been made to withhold from the profession and the public the agent employed, and to secure a proprietary interest therein! Here, as in all other instances, the restrictions of the National System of morals have reference to the welfare of the community, and not to the selfish interests of the medical profession.'' The fourth section of the sixth article of the second chap- ter of the abstract has no place whatever in its letter. The practices it decries are as strongly condemned by the spirit of the medical laws of 1847 rightly interpreted. It belongs to local associations to declare such or such conduct un- becoming a loyal physician and gentleman, and to take fit action thereon. The conduct specified in the section in question degrades not only the general profession but the vile guilty culprit, and unfortunately prejudices the undiscriminating public against the local physicians. The committee in charge of the abstract seems to have been 330 APPENDIX led to insert this fourth section because of the well-known corrupt and dishonorable practice, in some parts of the country, of openly offering the percentages of moneys in question and that these moneys have been habitually received and accepted; and when the demand of a com- mission is denied, the unfortunate patient, victim of the rapacious proponant or broker, is sent to any other phy- sician who will pay the required dishonest commission. Thus making a vile trade of a noble profession by buying and selling patients like chattel to the dealer or pigs to the slaughter house! Such is the morally debauched condition of many in whose souls the spirit of the grand National System has not entered, that they are even willing to receive from tradesmen commissions on business sent to their shops. 331 VIII ANALYSIS OF DOCTOR FLINT'S COMMENTARIES The subjoined analysis of Doctor Austin Flint's admir- able commentaries designed as a plea for the maintenance of the American system of medical morals, is intended for those who have not read that valuable contribution to the moral philosophy of medicine. The work begins with a modest preface, characteristic of the truth-loving and guileless author who died full of years and honors, deeply regretted by all who knew him. The commentaries, which show ripe scholarship, good taste and loftiness of mind, were composed in moments snatched from his hours of rest and were truly a labor of love. In the introductory remarks the author says: "A reader who has given to the subject little or no attention may be supposed to ask, 'wherefore the propriety of recognizing the principles of duty applied to medicine as constituting a distinct branch of moral science? Are not the rules . . . . which would govern the practiser of medicine the same as in other applications?' There are certain fundamental truths which, of course, underlie all possible applications of morals; but the adaptation to different conditions of life call for a separate consideration. 332 APPENDIX . . . . The rules of conduct adapted to the peculiari- ties of medicine constitute medical morals. These rules have a moral weight. Medical etiquette, on the other hand, consists of the forms to be observed in professional intercourse. These are conventional. They have not the binding force of moral rules; nevertheless, they claim observance. The medical profession receives not a little ridicule for observing rules of etiquette, but their observ- ance is a protection against not only embarrassment and confusion, but misapprehensions and dissensions, injuri- ous alike to physicians and patients. If there be ground for a distinct system of morals applied to medicine, the rules of conduct which the system requires should be codified. A system of morals adopted by the profession represents the views held by the majority of its members, and is, therefore, binding on all. It is indispensable for the sake of reference whenever differences of opinion arise. It indicates the proper course to those whose moral per- ceptions may be defective. It may prove a safeguard against the bias of personal interests. It thus contributes to the purity and dignity of the medical profession. Much would be gained in the popular respect for the profession, were the public better acquainted than they are with the rules by which its members assume to be governed. It is, perhaps, a common impression that the objects of a sys- tem of medical morals have exclusive reference to the interests of the medical profession. So far from this, the objects are of far more importance to the public welfare than to physicians." .... Farther on in the intro- 333 MORAL PHILOSOPHY OF MEDICINE duction he gives the origin of the system, and then con- cludes with a statement of the arrangement proposed for the commentaries. The work is divided into three chap- ters, which embrace the entire system, and to each section appropriate comments are appended. Chapter I.-The Duties of Physicians to their Patients, and the Obligations of Patients to their Physicians Section i of this article is so clearly defined and so well adapted to the instruction of young physicians, that it is difficult to conceive what could have induced any physician to suggest its suppression. That its provisions are self-evident to physicians of experience is not doubted, but they are all necessary for the information of beginners, and are as brief as consistent with distinct statement. "They antagonize," says Dr. Flint, "undue influences aris- ign from self-conceit, an irritable temper, indolence, devo- tion to pleasure or to occupations which divert from pro- fessional duties, and all mercenary considerations. At the same time, they do not contravene self-respect and a proper regard for personal interests." There surely is no doubt of the necessity to tell young physicians of their obligations to obey promptly the calls of the sick; that their mission is always one of mercy; that the responsibil- ity they incur in the discharge of their duties is great, and that since their work is generally performed in privacy, the only punishment for carelessness or neglect is through ARTICLE I.-DUTIES OF PHYSICIANS TO THEIR PATIENTS 334 APPENDIX the stings of conscience and the loss of self-respect. These injunctions and all others in the system are ennobling and serve to soften the manners and expand the affections of the young, and form them to that propriety and dignity of conduct which are essential to the character of gentle- men. (Percival.) The third sentence of this first section is a wholesome amplification of the preceding sentences, and its appropriateness will probably be admitted by the majority of readers. The last sentence of this section has been very harshly and unfairly criticised on various occasions. Careful examination shows that it is clear, that its words were well chosen, and that it is necessary. How merciful on the part of the physician, how comforting to the patient, when firmness is tempered with tenderness; how noble it is in the physician to be tenderly firm, and how necessary it often is for the physician to be conde- scending; that is, to be yielding in minor details so that his authority may be greater in important particulars for the good of the sufferer! And how can he fail to inspire gratitude, respect and confidence, if he observe these injunctions in letter and spirit? Sec. 2.-In the first sentence of this section the word attention, which occurs in the third sentence of the preced- ing section, is repeated, but the repetition seems justifi- able. The whole sentence, indeed, is complementary to that third sentence, and gives greater force to the injunc- tion. The second sentence is rightly placed and pertinent. Bodily infirmity often leads to mental imbecility, or to unreasonable caprices, therefore young physicians are 335 MORAL PHILOSOPHY OF MEDICINE enjoined to be indulgent and to make due allowance for the whims of the afflicted. None can, with justice, object to the three sentences that relate to the observance of secrecy, which are paraphrased from the Hippocratic oath, and there is not a court of law in the United States that is likely to refuse protection to the physician in the circum- stances detailed in this section. The commentaries of Dr. Flint on this second section fill ten pages and are well worthy of careful study. Sec. 3.-is short, incisive, explicit, self-explanatory, and necessary. It receives from the able pen of Dr. Flint an appropriate commentary which is quite sufficient to show its great utility. Sec. 4-is the longest in the system; it contains a little more than two hundred words in six aphoristic sentences, and is so instructive and valuable to young physicians that not a single part or word should be retrenched. "Undue solemnity, anxiety and apprehension in the looks, manner or words of a medical attendant on the sick, are ex- tremely unfortunate-they discourage patients; whereas, on the other hand, a cheerful mien, calmness, of deport- ment, and verbal assurances, sometimes accomplish more than drugs." All that is embodied in this section is self- evident and well known to experienced physicians, but is absolutely necessary for beginners. Sec. 5-contains wholesome admonitions to young physicians who are too apt to form gloomy prognostica- tions in cases of serious disease, and sometimes even to abandon the patient, thinking there is no hope of his 336 APPENDIX recovery and being delicate respecting the demand of fees which they believed might not be honestly earned should they continue their visits* The very time of the cessation of such visits may have been the climax of a crisis which, ending soon after the arrival of another physician, is fol- lowed by rapid recovery. In such a case the retiring physician is discredited by the family, even if his successor explains the case and honestly endeavors to exonerate him. This alone gives great value to Section 5, but it contains other points of no less value. Moreover, in truly hopeless cases, the physician "can often do much toward lessening pain or discomfort-mental and physical; he can contribute to euthanasia, and he can comfort those who surround the bed of death by assurances that in the 'last agony,' as it is miscalled, these manifestations of distress are usually unattended by conscious suffering." Sec. 6.-The perusal of Dr. Flint's commentaries will convince the most incredulous of the necessity of this section. He says in the concluding sentences: "Consul- tations, when their true objects are recognized by all parties, are of great comfort to an attending physician. Undoubtedly, a reason for their being distasteful to him often is a want of full confidence in the honor of the con- sulting physician. Hence, it is important that physicians comply conscientiously with the rules laid down in respect of consultations." Sec. 7 is quite as important as any other section of Article 1: "It is undoubtedly true that persons will often listen more considerately to counsels or remonstrances 337 MORAL PHILOSOPHY OF MEDICINE from a medical adviser than to those of relatives, friends and neighbors, or even to the admonitions of the clergy. It is, perhaps, true that most persons are influenced more by considerations which have reference to life and health than to those which appeal directly to the moral nature." These two sentences show but a small part of the excellent advice compressed in less than a page of Dr. Flint's precious work. ARTICLE II.-OBLIGATIONS OF PATIENTS TO THEIR PHYSICIANS Dr. Flint prefaces this article as follows: "There are several reasons why this portion of the system, calls for but little in the way of commentary. In the first place, the commentator being a member of the medical profes- sion, it is a matter of delicacy not to dilate too largely on the obligations of patients to their physicians. In the second place, although in the preparation of these com- mentaries the hope is entertained that they will have inter- est for non-medical readers, there is probably little ground for the expectation that they will have an extensive popular circulation. In the third place, a large propor- tion of patients are fully sensible of their obligations to their physicians; and, lastly, the portion of the system which defines the obligations of patients to their physicians is so clear and comprehensive as not to offer much scope for addition or elucidation. For these reasons, instead of making each subdivision a separate heading for com- ments, the entire article will be first given, and afterward, 338 APPENDIX brief remarks on the topics which it embraces, following the order in which they are presented in the system." Sections i to io inclusive.-Although the author says, in his prefatory note, that this article calls for but little in the way of commentary, he nevertheless comments on its ten sections in five pages, and in the most attractive and lucid style which can not fail to carry the fullest con- viction of the necessity of every syllable contained in the article. Chapter II.-Of the Duties of Physicians to Each Other and to the Profession at Large ARTICLE I.-DUTIES FOR THE SUPPORT OF PROFESSIONAL CHARACTER Sections 1,3,4, 5.-The detractors of the system seem to regard the first, third, fourth and fifth sections of this article as unnecessary. They entertain this baseless opin- ion, probably because they have not read the article with sufficient attention or reflection. The following passages are therefore extracted from Dr. Flint's commentaries to show the utility of these sections, particularly to young physicians: "It may be said that the sentiments expressed in relations to the 'duties for the support of professional character,' contained in the first two sections under this head, are mere truisms and platitudes. This may be said with regard to any collection of moral principles for the regulation of human conduct. Experience shows the importance of the embodiment in language of moral prin- ciples pertaining to other of the relations of life, and there 339 MORAL PHILOSOPHY OF MEDICINE is reason to believe that this portion of the system has not an inconsiderable influence upon the character of the pro- fession, by inciting its members to become worthy of it, and to render it still more worthy of the estimation in which it is generally held by the public." The fourth section must be especially disliked by the dissenters, on account of the nature of its sentiments which are so distinctly stated as to allow no chance for misunderstanding, either in letter or spirit. Dr. Flint thus comments on this important section: ''There can be no difference of opinion in the minds of worthy physi- cians as to the acts which in the fourth section of this article are specified as derogatory to the dignity of the profession. But the propriety of the interdiction of these acts by the system is not always appreciated by the pub- lic. As a reason for their being interdicted as 'highly reprehensible in a regular physician,' it suffices to say that 'they are the ordinary practices of empyrics.' The public should understand that these practices are criteria of irregular or unworthy practicers. With this understand- ing, if persons consent to be influenced by such acts, the responsibility for consequences lies with themselves. The credulity in regard to therapeutics, which is inherent in the minds of many, will doubtless always afford encour- agement for a continuance of the various meretricious methods of obtaining credit for superior medical or sur- ical skill." The fifth section, which is as concise as it is explicit, is doubtless regarded as oppressive by many offenders. Here 340 APPENDIX are Dr. Flint's remarks upon its provisions: "The grounds for the injunction not to patent remedies or surgical instru- ments, and not to dispense secret nostrums, are not always appreciated by the public. Some appear to think that it is dictated by jealousy or professional prejudice. The reasons are concisely but clearly stated in the system. Imagine Jenner to have applied for a patent giving exclu- sive property in vaccination, or keeping it a secret! How different would the names of those identified with the discovery and introduction of anesthesia in surgical and medical practice appear in history, had the attempt not been made to withhold from the profession and the public the agent employed, and to secure a proprietary interest therein! Here, as in all other instances, the restrictions of the system of morals have reference to the welfare of the community, and not to the selfish interests of the medical profession." Sec. 2 of this article is not contained in Dr. Flint's book, probably because he took for his commentaries the original of 1847; this second section having since been inserted. It explains itself and will surely not be objected to by the profession. ARTICLE II.-PROFESSIONAL SERVICES OF PHYSICIANS TO EACH OTHER Section i.-Only a few extracts are made from the brief but wise commentary to this article: "From the best motives, the professional friends .... of a sick physician are apt to call upon him, inquire into his 341 MORAL PHILOSOPHY OF MEDICINE case, proffering their opinions and advice, without any concert between them, and the result is that a medical patient may receive no systematic treatment Except in cases where close intimacy dictates a deviation from the rule, a physician should not ask to see another physician in illness until requested to do so. The mani- festations of interest and sympathy should be limited to kind messages and inquiries through others Medical services rendered to members of the profession should be gratuitous A request to present a bill for services .... should never be made. Such a request implies an expectation that it will not be com- plied with. Any pecuniary acknowledgment by a mem- ber of the profession for medical services should be made strictly as an honorarium." ARTICLE III.-OF THE DUTIES OF PHYSICIANS AS RESPECTS VICARIOUS OFFICES Section i.-This article was lately objected to by a dissenting writer who wished it expunged on the ground that it "refers to a question regulated by custom," losing sight of the fact that the system is a statement of well- established customs. The following extracts from Dr. Flint's commentary are intended to show the necessity of retaining this third article: "The system of morals defines the line of conduct in many instances of which it may be said that a proper courtesy and sense of honor should suffice without formal moral rules. Assuming that an adequate degree of courtesy and sense of honor belong 342 APPENDIX to members of the medical profession in general; to as- sume this for all members would be to claim for medicine, in a moral point of view, a position far above that of any other pursuit. Moral rules, therefore, are needed for a greater or less number of physicians. But, irrespective of any question of moral delinquency, rules are useful by indicating precisely what is to be done under certain cir- cumstances, thus preventing embarrassment and saving the trouble of discussion in particular instances Vicarious offices offer an opportunity for one deficient in a proper sense of honor to undermine the confidence of patients in their physicians. This may be done, not openly, but insidiously, by questions, expressions of sur- prise, over-assiduous attentions, etc. It will do much toward neutralizing such violations of honor, if the public be made acquainted with the article of the system which relates to these offices. Patients will be led to understand the motive which prompts such dishonorable efforts, and, so far from accomplishing the objects, they will justly react upon unworthy members who act in opposition to the spirit of the system. ARTICLE IV.-OF THE DUTIES OF PHYSICIANS IN REGARD TO CONSULTATIONS Section i.-This section of the fourth article seems to be the objective point of those who desire revision of the system, their aim being to expunge the whole of the first section. Dr. Flint says: . . . of the entire system this section alone has occasioned dissension." He further 343 MORAL PHILOSOPHY OF MEDICINE says that he is "one of many who think that the system is here open to objection; not, however, in spirit or intent, but in phraseology, The last sentence is the part con- cerning which an objection may fairly be raised "The real objection to those whose practise is based upon an exclusive dogma is that they are opposed to the regu- larly organized profession and use adjectival titles as trademarks. No therapeutic differences could exclude them from the regular profession if they were to drop their distinctive titles and abide by the laws of the pro- fession. The most liberal explanatory declarations were made, after the publication of Dr. Flint's commentaries, by the American Medical Association, through a special committee of which Dr. Flint was a member, thus entirely disposing of this question. All of Dr. Flint's comments on this first section are well worthy of insertion, but a few extracts from them will suffice to show how temperately he has written: "It is fair to conclude that the framers of the system had no feeling of illiberality, and no intention to interfere with the practice of medicine, under any circumstances, in the cause of humanity. The system declares explicitly that, 'in consultations the good of the patient is the sole object in view,' and enjoins against declining consultations on the score of fastidiousness. The restrictions of the system are in nowise inconsistent with the demands of humanity in cases of emergency.'' "In saying that certain practisers are not to be con- sidered as regular or fit associates in consultation, it is 344 APPENDIX neither said nor implied that a physician should not see a patient even with these practisers when humanity requires him to do so. The tenor and spirit of the system through- out are opposed to any act of professional inhumanity. Moreover, in particular cases, the physician must be the judge of his duty in this regard. Practically, there need be no difficulty how to obey the dictates of humanity and, at the same time, conform to the system, under the guid- ance of a conscientious regard for both. The objection- able point in the system is that which makes 'a practice based on an exclusive dogma' the ground of a refusal to meet practisers in consultation. This is not a valid ob- jection. Any physician has a right either to originate or adopt an exclusive dogma, however irrational or absurd it may be. Dogmas have prevailed more or less in the past history of medicine. If in a consultation there be lack of agreement respecting either diagnosis or treatment, the system indicates in another article precisely the course to be pursued. The true ground for refusing fellow- ship in consultations, as in other respects, is a name and an organization distinct from, and opposed to, the medical profession. Whenever practisers assume a distinctive appellation, thereby assuming to represent an essentially distinct system of practice, taking an attitude of antago- nism to the regular profession, seeking popular favor on the ground that they belong to a 'new school,' based on truth and productive of good, where as the regular profession belong to an 'old school,' based on error and productive of harm-how can there be fellowship either in consulta- 345 MORAL PHILOSOPHY OF MEDICINE tions or in other respects? If they who thus assume an attitude of antagonism to the medical profession conscien- tiously hold to the distinctive tenets which, as they pro- fess, are the ground of their antagonism, how can they consistently desire to meet members of the latter in con- sultation; and, with opposing views of therapeutics, how could such consultations accomplish the 'sole object in view,' namely, 'the good of the patient?' If such con- sultations were permissible, professional fellowship would be rendered immoral on the ground of complicity in a fraud upon the public. It is hoped that the body from which the system emanated - namely, the American Medical Association-will adopt such modification in the phraseology of this section as will place restrictions on consultation, not on the ground of doctrines or forms of belief, but on separation from and avowed antagonism to the medical profession." Dr. Flint's hope was soon realized, for the American Medical Association adopted the series of explanatory declarations to which reference has already been made. ''Under no circumstances can there consistently be fel- lowship with any class of practisers who adopt a distinc- tive title as a trademark, and who are banded in order to impair the confidence of the public in the medical profes- sion. To take the ground that, because the Legislature of a State has placed on an equal legal footing, different classes of practisers, those of one class cannot refuse to consult with those of another class, is as absurd as to assert that a Jewish Rabbi is bound to exchange pulpits 346 APPENDIX with Christian ministers, or the latter to affiliate with Mormon elders for the reason that, in the eye of the law, in this country, all religious denominations have equal rights. The people demand of their legislators the enact- ment of laws for the protection of life, liberty and property, but they do not look to them for the institution or the interpretation of systems of morals "There are many, not of the medical profession, who have been led to believe that its members are bound to uphold antiquated traditional doctrines. Many seem to think that the 'old school practisers,' as they are derisively called, are committed to a system of practice expressed by the term, allopathy. All medical men know that, so far from these popular notions being true, they are quite the reverse of the truth Allopathy . . . . is simply a term of reproach. It has no pertinency as applied to the medical profession. As is well known by all conversant with the history of medicine, doctrines and practice undergo changes in proportion to the advance- ment in the several branches of medical knowledge and accumulated experience. The tendency, certainly, within the last half century has been to adopt new views too readily, not heeding sufficiently the restraints of a rational conservatism. It is desirable that the public should understand that the medical profession is in no sense a sect, as implied by the name, allopathy. It allows the utmost latitude of opinion. The sectarians in medicine are those who have professed faith in tenets to which they are bound, at least ostensibly, to adhere. Opinions held 347 MORAL PHILOSOPHY OF MEDICINE by members of the regular profession, however at variance with those generally entertained, and however absurd, may fairly give rise to criticism and ridicule, but they can not be made occasions for professional discipline. With a proper understanding of the reasons which actuate mem- bers of the medical profession in declining to meet irregu- lar practisers, their action cannot be attributed to either jealousy or prejudice. Their action, indeed, may involve the sacrifice of personal interests, and it concerns the public welfare not less than the dignity and honor of the profession. Let the statement be repeated, until no longer necessary for the information of the public, that there are no allopathic practisers of medicine. A regular member of the medical profession should never even tacitly admit the propriety for this designation. Let it be understood by the public, as well as by the profession, that there is no necessity for a schismatic separation from the regular profession on account of any peculiarity of doctrine. Such a separation is not from necessity but for the purpose of obtaining practice." Secs. 2, 7, 10.-"These three sections of Article IV, although not occurring consecutively in the system, are here collocated because they contain moral rules which have reference to the relations of consulting with attending physicians." The following passages in the commentaries on these three sections serve to show what are some of the popular errors respecting consultations of physicians: "One of these errors is that a consultation, when requested by patients or their friends, implies, as a matter of course, 348 APPENDIX dissatisfaction with the services of the physician in attend- ance. The request should never be considered in that light. Connected with this error is another, namely, that it is the office of a consulting physician to pronounce a judicial decision respecting the treatment which has been pursued, or which is being pursued, by the physician with whom he is requested to consult. This is not the office of a consulting physician. He should be reserved in forming an opinion as to past treatment, inasmuch as the case was not under his observation, and it would be unfair to judge of circumstances which he had not ob- served; hence, an opinion unfavorable to the past treat- ment, if indiscreetly formed and still more indiscreetly uttered to any but the attending physician, might do the latter great injustice Still another error is to assume that a physician in consultation has more knowl- edge or skill than the attending physician, and that, con- sequently, the latter is to be subordinate to the former in the management of a case. A consulting physician may or may not be the superior in knowledge or skill These errors, prevailing somewhat in the profession, have a much greater popular prevalence. It is owing to their prevalence that medical consultations are not more fre- quent. Patients and their friends often hesitate to pro- pose a consultation from a desire not to imply want of confidence in the attending physician The true ground for a medical consultation is the benefit which may be derived by bringing the judgment of two or more minds to bear upon a case. There are few things in human 349 MORAL PHILOSOPHY OF MEDICINE life which are generally considered more precious than health, and there are few calamities which, in the minds of most persons, it is more desirable to postpone than death. It is, therefore, a singular anomaly that confer- ences on matters of far less importance than those relating to health and life, such as business interests, politics, social life, etc., are more frequent than medical consultations. In cases of disease, these are frequently delayed until the condition of the patient is hopeless, and when no real benefit can possibly be derived from them. Not only should they be had earlier, but they should not be limited to cases in which there is more or less immediate danger. The fact that they are apt to be thus limited renders them a source of apprehension to patients, and, for this reason, they are sometimes delayed." Secs. 3, 4 and 5.-The rules given in these three sec- tions relate to the etiquette to be observed in consulta- tions. Dr. Flint's comments, of five pages, on these sec- tions are well worthy of careful study, and show how important it is, in a system of medical morals, to set down rules of etiquette as well as of morals. Sec. 6 was accidentally omitted in Dr. Flint's book, but is commented on with Sections 3, 4 and 5. Secs. 8 and 9.-After a very judicial commentary on the eighth and ninth sections, Dr. Flint adds: "There are some points relating to the morals and etiquette of con- sultations which are not touched upon in the system. One of these is the duty of a consulting physician who may be asked to take the place of the attending physician in a 350 APPENDIX case while it is in progress. It may happen that there is dissatisfaction with the services of the attending physi- cian, of which the consulting physician may not have been aware, and it is proposed that the former relinquish the case into the hands of the latter. This transfer of a case is justifiable on but one ground-namely, that it is in accordance with the wishes of the attending physician. The consulting physician should satisfy himself on this score. It is not enough that the attending physician con- sent. He will, of course, do so if requested. If not in accordance with his wishes, the transfer should be posi- tively declined by the consulting physician. "Another point relates to subsequent attendance by the consulting physician. After a case is ended, in another illness the patient may request his services as attending physician. There may be exceptional instances, but, as a rule, such a request should be declined. If acceded to, it should be after a full understanding with the physician previously in attendance. This and the preceding rule are essential, in order that consultations may be held without risk of injury to the feelings and interests of the attending physicians. A physician in consultation, if actuated by proper delicacy, and a sense of honor, will, of course, sedulously guard against the possibility of his services being preferred to those of the attending physician. "Another point may be referred to. It sometimes hap- pens that a change of an attending physician is made while another physician is associated in consultation. Shall the latter remain in consultation with the successor of the 351 MORAL PHILOSOPHY OF MEDICINE former? As a rule certainly not. If the change has been made on account of dissatisfaction with the medical treat- ment, the consulting physician is as responsible for this as the attending physician, and he should decline to remain in consultation. If other reasons have led to the change, there are obligations of courtesy which are not to be ignored. There should be a full understanding with the attending physician who is superseded. The 'good of the patient' is, of course, a primary consideration. The action must be determined by thecircumstances proper to each case. "There may be circumstances which should properly lead a consulting physician to decline further association with an attending physician, although no disagreement in consultation had occurred. If the attending physician fail to carry out measures agreed upon, either intentionally or from inefficiency.it isnot just for theconsultingphysician to be held to an equal responsibility in the case. It is the duty of an attending physician to carry out faithfully the course of treatment decided upon, and, if he persistently fail in so doing, the consulting physician is justified in declining to be longer associated with him.'' Not a word can, with propriety or consistency, be re- trenched from Article IV relating to the morals and eti- quette of consultations. ARTICLE V.-DUTIES OF PHYSICIANS IN CASES OF INTERFERENCE Sections i to 8 and Section io.-The two extracts made from the commentaries on these sections will suffice to show their import: 352 APPENDIX "The foregoing sections of the system embrace points in morals and etiquette, the propriety and importance of which no member of the medical profession will undertake to deny. Their observance is essential to the harmony, good fellowship and mutuaj cooperation of practisers of medicine, thereby contributing to the honorable charac- ter of the profession, to the public confidence in regard to it, and to its usefulness in the cause of humanity. The question, however, may be raised, Is it necessary to embody these points in morals and etiquette in formal rules; that is, would not physicians regulate their conduct equally well without the latter? The affirmative answer to this question would imply that all those admitted to the ranks of the medical profession found 'their expecta- tions of practice upon the extent of their qualifications and not on intrigue or artifice.' No one will venture to claim for all members of the profession that purity and high moral tone which are implied in the affirmative answer to the question. It must be admitted that these rules are not infrequently violated. Does it follow that the rules are useless? Certainly not. The fact only proves that knowledge of rules does not always secure their observance. This is true, not alone in medical morals, but in theology, law and every department of morals. That prescribed rules of medical morals influence more or less the conduct of physicians cannot be doubted. This is true as regards other duties, else wherefore the propriety of such rules applied, not only to the higher moral relations of human life, but to those of minor importance, and even the trivi- 353 MORAL PHILOSOPHY OF MEDICINE alities of social intercourse. To do away with moral rules for the reason that they are not always observed would be in opposition to human experience and conducive to anarchy. Prescribed rules of conduct are of use by giv- ing distinctness and force to, popular sentiment. More- over, the knowledge of rules affects the conduct of those who, not devoid of rectitude, pursue the wrong because they do not know the right. Rules thus tend to nullify the temptations and the specious pleadings of apparent self-interest. " It has been argued for the inutility of rules in medical morals, that penalties for their non-observance are with difficulty instituted and enforced. This argument is as illogical as in its application to all moral duties. It is a feature of the system of medical morals that it takes no cognizance of penalties for violations of its requirements. It appeals solely to the judgment and conscience. Meas- ures for the enforcement of its rules are left entirely to the discretion of local associations " Sec. 9 is commented on by the author with the same judicial ability as the other sections of this and all of the articles of the system. Sections i and 2.-The following, among the comments on these two sections, are well worthy of reproduction in this place to refresh, in the minds of physicians, the salu- tary maxims set forth in this part of the system and in the commentaries: ARTICLE VI.-OF DIFFERENCES BETWEEN PHYSICIANS 354 APPENDIX "Harmony among physicians is most desirable, not alone for the comfort of those concerned, but as conducive to the honor and usefulness of the medical profession. It is essential to cooperation in medical consultations, in measures for public health, etc. For the maintenance of harmonious relations, local associations are important. 1 n places of small or moderate size, these associations should embrace all the members of the profession of the commu- nity who are in good standing. In this way are avoided the evils of cliques, which are to be deprecated. The local associations should have more or less of a social char- acter. They afford opportunities for intimate acquain- tance, for the explanation of misunderstandings and for their prompt adjustment. Observation will show that, in the places in which such associations exist, much more harmony and good fellowship prevail than in places in which physicians are not brought together in social inter- course. Controversies and contentions, however, cannot always be avoided. They will be terminated with the more difficulty the longer they continue. The system of morals, therefore, judiciously instructs that, if not ter- minated immediately, they are to be adjusted by arbi- tration " ARTICLE VIL-OF PECUNIARY ACKNOWLEDGMENTS Section i.-This short but important article receives a full commentary of a character such as could have been given only by a physician of the long and extensive experience o the venerable author. The following ex- 355 MORAL PHILOSOPHY OF MEDICINE tracts give some idea of the nature of the comments: " By no process of distortion can this article of the system, be made to inculcate a combination, after the manner of trades unions, to establish and enforce a certain rate of wages for medical services It is plainly im- portant, for the convenience of patients, that in every community there should be an understanding as to the customary fees for the different kinds of service which medical men are expected to render Exclu- sive of exceptional instances, .... the adoption of some general rules, and their recognition within and without the profession, obviate the necessity of questions, explanations and discussions, which are often embarrass- ing and disagreeable." "The poor policy of under-bidding other physicians, for the sake of gaining practice, would probably deter those from pursuing it who might be so inclined Few patients are disposed to select a medical adviser be- cause he places a low pecuniary valuation on his services. . . . . The system by no means interdicts deviations from the general rules according to varying circumstances. It is to the honor of the profession that the circumstances are few in which efforts for the relief of suffering and the preservation of life are withheld on account of the inability to make an adequate pecuniary acknowledgment. The circumstances which lead physicians from sympathy to deviate from the general rules are often not apparent to others. Few persons outside of the medical profession are aware of the extent to which the services of its mem- 356 APPENDIX bers are freely rendered, with but little or no compensa- tion; hence, one reason for an exaggerated estimate of the incomes of those largely engaged in practice, and for the fact that the majority of practisers, after a long pro- fessional career, leave but little property " " Extraordinary services rightfully claim deviations from the general rules in respect of fees. Detentions or constant attendance, involving sacrifice of interests, un- usual fatigue, or impairment of comfort, and visits requir- ing traveling and absence from home, are in this category. No one but the physician himself can place a valuation on such services, and it is his right to do this, provided there be an understanding before the services are rendered." Chapter III.-Of the Duties of the Profession to the Pub- lic, AND OF THE OBLIGATIONS OF THE PUBLIC TO THE Profession ARTICLE I.-DUTIES OF THE PROFESSION TO THE PUBLIC Sections i, 2 and 3.-The commentaries on the several articles and sections of this chapter are of the same high order as those of the first and second chapters. They appeal to the noblest sentiments of the ideal physician and sanitarian; they point out most distinctly the recipro- cal relations and duties of the profession and public; and they expose the fallacious reasoning of those who assert that the public has nothing to do with, and should neither know of, nor care about, the laws governing the conduct of physicians. The following extracts from the comments 357 MORAL PHILOSOPHY OF MEDICINE on the first three sections of Article I will serve to exem- plify their tone: "The more physicians are led to regard medicine in its humane and noble aspects, the more they are reconciled to its hardships, and the more they are incited to do all in their power to maintain its character and usefulness. The feeling that honor is reflected by membership of a profes- sion which professes to be governed by the system of Med- ical Morals conduces to a high moral tone, and it is in this way that the system is of great service. It is a beautiful feature of the system that it aims solely at the influence of its moral rules on the mind irrespective of any penalties. It is based on the principle that moral rectitude is pro- moted more by fostering upright sentiments than by the punishment of offenses." "The profession is entitled to whatever of praise belongs to courage in the performance of professional duty, albeit the courage has no recompense beyond the satisfaction of having followed the dictates of duty. The physicians' roll of honor is the list of those who have died in the perform- ance of professional duty. The history of every epidemic disease furnishes such a list. The risk of life was simply a duty, but who will refuse to accord to it nobleness? Who would remove from the system that portion which enjoins upon physicians that, when pestilence prevails, 'it is their duty to face the danger, and to continue their labor for the alleviation of suffering, even at the jeopardy of their own lives?'" "A broad distinction, in respect of pecuniary acknowledg- 358 APPENDIX merits, exists between the duties which every physician owes to the public in behalf of matters embraced in pre- ventive medicine and the duties connected with legal ad- ministration of justice. Whenever called upon by legally constituted authorities to give advice or expert testimony at coroners' inquests or in courts of justice, in relation to medical questions, physicians should be paid for their services. In view of the services rendered to the public without compensation, for those just referred to there should be adequate pecuniary acknowledgments. Inves- tigations in cases of supposed insanity, of homicide by poisons or other means, etc., and post-mortem examina- tions, made under instruction by authorities, claim ample remuneration. There is no good reason for physicians being expected to perform these duties gratuitously. Much injustice is often done to the medical profession in regard to these duties. Physicians should not fail, from a sense of delicacy, to assert their rights in this regard, and they should endeavor to lead the public to recognize the propriety of so doing." S^c. 4.-The commentator treats the subject of this section with his wonted skill and sound judgment, tells many solemn truths in a simple style, without the least semblance of magisterial assumption, touching the sundry forms of charlatanry and their dupes, and comments briefly, but with energy, upon the evils of proprietary medicines and the no lesser evil effect of physicians' certifi- cates indorsing these and other advertised medicinal agents. 359 MORAL PHILOSOPHY OF MEDICINE ARTICLE II.-OBLIGATIONS OF THE PUBLIC TO PHYSICIANS Section i .-It is no fault of the public if there still exist many errors respecting the characteristics and moral status of regular physicians and the nature of the professional relations they bear to individuals and to the community, for little if any information thereon has appeared in lay magazines. The time seems to have come to furnish the American people with this much needed information which they have every right to demand of the profession; and until it is given, the people will likely continue to look upon the regular profession as illiberal and unprogressive, and upon medicine as kept, by its devotees "for their own selfish ends," in a state of occultation to the great injury of the public. "A just appreciation of medical qualifications by the public is desirable as an incentive to members of the pro- fession to aim at these, and as a reward for their possession. In these points of view, it is discouraging to the votaries of true science for the assumption of ignorance and em- piricism to be successful in obtaining popular distinction. The public cannot be expected always to judge correctly between real qualifications and false assumptions. True distinction in medicine, therefore, must be based on the opinions of unbiased medical men." "The apathy and indifference on the part of the public to medical education is a singular incongruity, in view of the immense importance of well-educated physicians to every community. The interests of medical education are 360 APPENDIX left almost wholly to physicians, whereas these interests concern the public vastly more than the medical profession. If the public could be made to see this subject in a proper light, there would be no lack of accommodations, provi- sions and appliances for all the departments of medical instruction." In his concluding remarks the commentator says: ''The proposal to write commentaries on our National system of morals may have conveyed to the minds of many an idea of presumption. The writer of the foregoing com- mentaries indulges the hope that their perusal has not sustained this idea, inasmuch as he has not ventured to take issue with the system on any important point except one-namely, the ground for refusing medical consulta- tions. Nor has he assumed to be an expounder of the system, but only to supplement comments in conformity with the spirit which pervades it. In fact, a leading motive has been to excite the attention of medical, and, perhaps, also, to the same extent, non-medical readers, to the system itself. There are many members of the medi- cal profession who never read the system with that degree of interest which it claims, and there are some who have never read it. These assertions are based on information obtained by personal inquiries. It is safe to say of the public that not one in a thousand knows anything of its character and provisions." Finally, the author made, in vain, the following appeal to those who wished to abolish the system: ''The action which substituted a new code for our time-honored Na- 361 MORAL PHILOSOPHY OF MEDICINE tional System of Morals has brought upon the profession of the State of New York a great disaster. It substituted for harmony, dissehsion, with all the evils flowing there- from-evils affecting not only the profession, but com- munities. Has this result been sufficiently considered? Granting honesty of purpose to those who originated and who have carried on with persistent efforts the movements against the National system, is it not the part of wisdom to pause and reflect upon these evils? Should not a measure fraught with such consequences command, to say the least, a large majority in its favor? Would it not be becoming in the ardent advocates of the measure to recognize the propriety of some approach to unanimity of opinion, and for this end be content to await the result of a fuller discussion and a longer period of deliberation?." The appointment, in 1847, by the American Medical Association, of a committee of wise and learned men to frame a system which might serve as a guide for profes- sional conduct, was a boon to the profession and to the public. This committee consisted of Drs. Isaac Hays, Emerson and Bell of Pennsylvania; Dr. Alonzo Clark of New York, and Dr. Arnold of Georgia, who, after examin- ing many systems of medical morals, adopted by local societies, and finding that they bore a close resemblance to each other and that they were derived from Percival's system, abbreviated the English document and adapted it to the use of the American medical profession. The adoption of this system has had the much desired effect of raising the standard of medical morals and thought in 362 APPENDIX the United States. Those least familiar with its provi- sions are its worst detractors who wish to destroy this monument of wisdom and justice which, with Dr. Flint's commentaries, is worthy of being translated into every foreign language, and of being published in every news- paper in the world, in order that all men, who can read, may know what scientific medicine means, and what are the reciprocal obligations of physicians and the public. This would operate more effectively than anything else toward the extinction of medical charlatanism and of the many kinds of irregularities practiced under the guise of benefiting humanity. 363 INDEX INDEX Abstracts, 328 Alliterations, 239 Appendix, 248 Aspirants, 2 Attendance on other physicians or their families, 197, 318 Attendance on own family, 197 Attendance on self, 197 Auditive sense, 106, 116 Authorship, 92, 215 Books, 91 Chapters, 248 Character, professional, ' 288, 3'5> 33i Charlatan, 100 Class Societies, 56 Coinage of words, 238 Compensation, 206, 334 Complaints, 82 Conduct, earliest principles of, >94 Conduct towards other physi- cians, §0 Consultations, 171, 200, 319, 343 Court, Medical, 299 Covenant, implied or special, >74 Diagnose, 226 Diet, 62 Differences, 202, 299, 324, 352 Duties, 287 Duties of physicians to each other, 315, 339, 341 Empiric, 100 Equipment, 91 European Centers, 104 Evolution of medical morals, 142 Exactness of names, 232 Explanatory Declarations, 308 Flint's Commentaries, 332 Florid writing, 239 Friendly visits, 188 Gustative sense, 109, 135 Hippocratic oath, 276 History, 18 Hospital discipline, 76 Hospital-internes, 70 latrium, 92, 1 52 Incurable cases, 170 Index, 248 Interferences, 201, 296, 321, 352 Interviews, 211 Introduction, 248 Language of medicine, 214 Law, the, 149, 278 Lectures, which to attend, 54 Library, 91 Life, length of, 253 Management of the sick, 79 Mannerism, 183 Matriculation, 55 367 INDEX Medical bulls, 243 Medicine, 8 Mental cases, 173 Misused words, 217, 224 Moral precepts, 155 Morals, medical, evolution of, 142 Music, 119 Myths, 36 National system, 304 Oath, the, 143, 276 Obsolete words, 239 Olfactive sense, 108, 129 Paragraphs, 242 Parentheses, 242 Patient and physician, 177, 334- 338 Patron, 230 Pecuniary acknowledgments, 204, 300 Perfumes, 132 Physic, 3 Physical exercise, 60 Physician, 3 Physician and patient. 159,313, 334 Politics, 102 Popularity, 183 Practitioner, 227 Practiser, 228 Precision, 241 Preface, 247 Profession and Public, 194, 300 335 Professional success, 86 Prognostications, 166 Prognostics, book on, 1 53 Public and physician, 302, 357 Public office, 211 Punctuation, 241 Quacks, ioo Quotations, 240 Reading, 58 Rebukes, 82 Relations to Fellow Students, 67 Relations to Teachers, 67 Reviewers, 94 Rounds, 81 Schools, American, 43 Schools of Medicine, 19 Secrecy, 163 Section organisations, 68 Senses, culture of, 105 Serious cases, 171 Sleep, 64 Social duties, 64 Sophomoric writing, 239 Speakers, 235 Specialism, 96 Student, qualities, 46 Student, requirements, 48 Style, 244 Sub-titles, 246 Surgery, 9 Tables of contents, 248 Tactile sense, 107, 122 Temples, 36 Tobacco, 63 Vicarious offices, 291, 342 Visitations, length and fre- quency, 165 Visiting Physician, 80 Visual sense, 112 Word-controversies, 217 Young writers, 217, 235 368