^^ VALEDICTORY ADDRESS, / ON THE ART OF EXAMINING THE SICK; DELIVERED TO THE GRADUATES OF THH MEDICAL COLLEGE OF OHIO; ON THE FIRST DAY OB MARCH, BY JAMES CONQUEST CROSS, M. D> Profenor of Materia Medica and Therapeutics in the Medical College of Ohio. LEXINGTON, KY, PRINTED BY N. L. FINNELL. 1836. Cincinnati, 2lfth July 183(5. Prof. James C. Cross: Dear Sir,—The valedictory address delivered by you before the Graduates of the Medical College of Ohio of the last session, and the citizens assembled on that occasion, not having been yet published, as we expected it would have been, we take this oppor* tunity of your visit to Cincinnati to ask of you a copy of it for publica- tion, in pamphletform, believing.that it contains much valuable advice to young men just entering upon the arduous and responsible duties of their profession. Yours, most respectfully. JAMES M. MASON, M. D. RICHARD EBERLE, M. D. STEPHEN BONNER, M. D. Pearl Street House, 28th July, 1836. Gentlemen:—Though I am not aware that the address to which you allude contains any very novel views of the subject on which it treats; if the observations.there embodied can, in any respect, promote the improvement of those for whom it was written, I willingly surren- der it into your hands. Be pleased, Gentlemen, to accept my assurances of respect and friendship. JAMES C. CROSS, Drs. Mason, Eberle& Bonner. ADDRESS. Gentlemek Graduates: You have now received the honors of the doctorate; the highest honors of a profession that deservedly ranks in usefulness, dignity and respectability with the most ennobling of the arts culti- vated by or practised amongst men. You now belong to a profession not less venerable for its antiquity than it is remarkable for the zeal and success with which its study has been prosecuted. Between you and those who were so recently your teachers, all technical distinc- tion, from this moment, ceases to exist; between you and the legiti- mate members of the profession, the line of demarkation has been obliterated and you have been elevated to a rank and placed on a foot- ing of perfect equality with them. This day registers your names with those of a long line of noble ancestry, whose intellectual achieve- ments have, generation after generation, through the ceaseless roll of more than two thousand years, enlightened and enlarged the sphere of your profession's usefulness. Nor, in after life, when in- firm and decrepit age shall have shed its sterile snows upon your brows, will you cease retrospectively to regard the day which wit- nessed this change as amongst the most eventful pf your lives;— eventful, because it produces an entire revolution in your habits and pursuits. You now, in a great degree, relinquish the silence and solitude of the study to engage in the toilsome and disquieting enter- piises of men;—you now exchange the guileless and unapprehensive simplicity of your youthful associates for the designing and dissem- bling hypocrisy of experienced rivals. Unhacknied and unpractised in the ways of (he world, you rejoice that you have passed the anxious period of pupilage, while your hearts leap for joy in anticipation of the pleasures which fancy, in the plenitude of youthful vigor, has scattered in unsparing abundance over the track which destiny has stretched before you. Exaggerated, however, as may be the visions vvhiqh you now cherish, I will not break in upon the joys of the present occasion, by reminding you in detail of the many difficulties you will have to encounter and overcome in their ultimate realization. Important as it is not to encourage ex- pectations too lofty and unattainable, it is equally binding upon the individual of enlightened views, who would reach respectability in any liberal profession, not to fasten his attention upon objects grovel- ling in their nature or debasing in their influence. Allured on by the former, the heart is sickened by the repeated prorogation of hope, and the mind is emasculated of its energy by the unmitigated horrors of relentless disappointment; while to be enamoured of the latter is 4 "to breed contempt, and that like gangrene, which if it seize on part of a character, is sure to corrupt all the rest by degrees." True wis- dom consists in keeping the objects of ypur ambition fairly within the sphere of reasonable attainment, while real folly is certain to place them upon a pinnacle so high as to be far beyond its capacity to reach. Nor are extravagant and unreasonable aspirations more characteris- tic of intellectual imbecility than unwavering confidence and un- flinching effrontery. Unmoved by the embarrassment which causes real genius to falter, 'fools rush in where angels dare to tread.' I trust you will pardon this digression and believe that I speak the feelings of my heart and the convictions of my understanding, when I say that, however deep and enduring may be the pleasure you ex- perience on the present occasion, it is participated by those who were recently your teachers. Not to do this, would prove them to be as insensible to the most striking manifestations of affection and re- spect, as to those traits of character which dignify and ennoble hu- man nature. When they call to mind the zeal and industry with which you have prosecuted the study of your profession; the order and decorum by which your deportment has been characterized; the uninterrupted harmony and fraternal regard which have marked your social intercourse; the respectful attention with which you have, on all occasions, and under all circumstances, treated your instructors; and above all, the highly creditable manner in which you have passed through the ordeal of a rigid and scrupulous examination, ihey feel called upon to say without pause or hesitation, that you richly merit the distinctions of this day. With such propitious guarantees of fu- ture usefulness and respectability, they willingly confide to your keeping the honor and dignity of that profession which has consti- tuted the study, the admiration and the business of their lives. During your stay in these halls, dedicated to the cultivation of Medical Science, your teachers feel a proud satisfaction in being able to declare that no circumstance has occurred to interfere, in any re- spect, with the harmony of ycur social and friendly intercourse with them. Appointed by the faculty that, recommended you for the lien- ors of the doctorate, to sever ibose ties by which you as pupils and they as instructors, have been kept together in close social and in- tellectual communion, it devolves upon me as a duty, and I therefore discharge it as a pleasure to say that they part with ycu with feelings of deep and unaffected reluctance. Suffer me, therefore, to endea- vor to dissipate, in some degree, the gloom with which the separation soon to take place, must necessarily overshadow the ceremonies of this occasion, by directing your attention, for a few moments, to a sub- ject, a thorough knowledge of which, cannot fail to increase the sphere of your usefulness, though it may not, as yet, have engaged your steady and serious reflection. The topic to which I allude, is one, the study of which cannot be prosecuted to much advantage du- ring the period of medical pupilage, at least, in those schools of medi- cine unprovided with infirmaries for the sick, and where, consequent- ly, clinical instruction cannot be conducted with any degree of suc- cess. Nor can proficiency in it be attained by those who have been educated in places thus imperfectly provided with the means of im- 5 parting practical instruction until after opportunities of considerable experience have been enjoyed. The subject to which I would invite your particular attention, is the art of examining those ailiicted with disease. Though I trust and believe you to be fully qualified triumphantly to overcome most of,, if not all, the difficulties which actual practice daily involves, be not surprised that I should remind you of the importance of an intimate acquaintance with the details of the art to which I have just adver- ted. To do this, I am Ihe more solicitous, because, while it may strike you as being simple end comparatively of inferior value, it is in truth, amongst the most difficult and important of the duties which the practice of medicine will devolve upon you. Difficult on account of the qualities of mind as well as of ihe extended and varied pro- fessional attainments which its scientific and successful practice im- periously requires; and important because, without a familiarity with all its details to deduce a sound and an accurate diagnosis or to institute a rational mode of treatment, would be utterly impractica- ble. Both are alike the offspring of a thorough methodical examina- tion. From any other source they cannot legitimately spring. Indispensably necessary as this art undeniably is to the rational and successful practice of medicine, it is no less surprising than true, that it is but rarely studied and still less frequently understood. This is particularly ihe case wilh the younger members of the profession, when they have not had opportunities of clinical observation in pub- lic hospitals or in the wards of a private practitioner. Ignorant of the art of methodically examining the sick, it would be supremely absurd for the physician to maintain that he can conduct an examina- tion either creditably to himself or beneficially to his patient. Im- possible as it would be successfully to deny the truth of this allega- tion, it is a subject not only of surprise, but a source of regret and deep mortification, to see how seldom, even from amongst the more experienced members-of the profession, it receives the attention to which it is justly and indisputably entitled. The discharge of this all-important duty, instead of being charac- terized by precision, exactitude and a regular detailed inquiry into all the circumstances of the cose, is done in a manner so desultory and careless as to prove that it inspires no interest and is consequent- lytxmsidered of comparatively little importance. Without order or method, the questions are propounded and too often without having any definite object in view or reflecting light upon the obscurities of any particular point. Nor is it uncommon to have questions asked that are not only irrevalent but absolutely unintelligible. From the unfinished investigation of one organ, the physician passes to the consideration of another, perhaps, distantly situated, without any ob- vious or assignable motive. Nor between the interrogatories ad- dressed to the patient, can the keenest sagacity always discern either a physiological or pathological connexion. It is1 not uncommon to hear either from a bad memory, inattention or ignorance, trivial and uninteresting questions more than once repeated, while those that are important and leading in their nature, are entirely overlooked and forgotten. 6 When an examination is thus conducted, objects are sure to bo confounded that are the most distinct, while those the most analogous are thrown widely asunder. Diseases the most simple are thus often rendered unintelligible, while those in any respect mysterious or com- plicated are never understood. Besides the inconvenience, not to say serious injury, that must be experienced from overwhelming a suffer- ing individual with a heterogenious string of unmeaning interroga- tories, to deduce from the data thus furnished an accurate diagnosis would be more difficult than to solve the riddle of the Sphynx. But of this we should not have so much reason to complain, could the doubt which hangs around the nature of the disease induce the phy- sician to pause before he ventures upon its treatment. Of this, how ever, he rarely dreams. To risk the life of a human being upon the validity of a random guess, is a circumstance of too common occur- rence to be a subject of serious or compunctious reflection. Why is this the case? Because the science of diagnosis and the art of examining the sick arc not sufficiently studied. Without a thorough acquaintance with the former, it would be preposterous to pretend to practice the latter. While the latter teaches you merely how to prosecute an examination, the former enables you to interpret the physical and vocal signs furnished by the patient. To make a suc- cessful practical application of diagnosis your examination must be conducted with strict regard to some settled and natural method. This, in truth, is so absolutely requisite that should you venture, irre- spective of method, to prosecute an examination in the presence of an educated and enlightened physician, he would denounce you as an awkward, illiterate and a blundering quack. It is the conduct of the physician, in the discharge of this duty, that announces in language not to be misinterpreted, whether he should be detested as an empy- ric or respected as an intelligent and accomplished physician. On a former occasion I endeavored to prove to you that systematic medicine constitutes a powerful remora to the rapid advancement of Ihe science, and here I may remark that its blighting influence has been felt in no respect more sensibly than in discouraging the study of diagnosis, and in bringing the 'art ofexamining the siclS into contempt. Supposing a principle to which all diseases are precipitately and gra- tuitously ascribed and considering certain symptoms as indicative of the existence of an hypothetically assumed pathological state, its in- quiries never extend beyond what it had predetermined to find. To the systematist every disease presents the same fundamental morbid lesion and is to be subdued by the same species of medication. He looks not for differences because his principles teach that they do not, nor can they exist. Nor is the course of treatment that should be pursued a source of the slightest uneasiness or perplexity. Hav- ing but one morbid state to remove or counteract, his whole therapia is compressed into a single favorite omnipotent remedy. It is easy to perceive that the mind of an abject slave of system enjoys a perfect sinecure; for the physician to think is idle and preposterous; to rea- son a work of supererogation; to practice his profession it requires less judgment than is displayed by the smith who skillfully shoes a horse, and less address than is evinced in the humblest mechanical 7 art. He is, in truth, a perfect automaton whose movements are regu < lated by the hand of a master. What better are such physicians, I ask, than the empyric or the nostrum-monger ? What chartered right have they to condemn the former or to denounce the latter? When called upon to speak of the former classes of individuals, instead of charging them with being swindlers and impostors, thoy should have been si- lent. The statue of Memnon itself had been mute as death at such a moment. How unutterably absurd is it to claim the high privilege of teaching when it is considered useless to think? How false is it to call that a science which has been swallowed up in a vortex of the most absolute Charlatanism to be found in the annals of imposture! But if a science, why should the Cava Pills repudiate the society of the Panacea of Swaim or the Number Six of Thomson ? In what re- spect is the former superior to the two latter? Tell me upon what ground do they differ? Like the waters of Alpheus and Arethusa, nothing is thrown into the one without being seen very shortly after- ward floating upon the bosom of the other. They are alike upon a footing of perfect equality, and should be condemned by every phy- sician who has any regard for himself, his profession or the public. This is a duty from the discharge of which no man of enlightened conscience can with safety shrink. Physicians are the guardians of the public weal, and they prove recreant to the obligations they have taken when they decline from any motive, whatever may be its nature to expose to public reprobation principles that are either erro- neous in theory or dangerous in practice. But my business is not so much to inquire into the prejudicial ten- dency of systematic medicine in a therapeutical point of view as it is to show that its direct effect is hypothetically to conceal those dis- tinctions which actually exist between diseases and which sophistry nevercan obliterate. This we see practically illustrated in the conduct of many of those who have brought their understandings into slavish subjection to the apochryphal authority of a system. Believing it to be utterly useless to institute a thorough examination, with the view of drawing an accurate diagnosis, as the same treatment will be adopted whatever may be the result, they take advantage of this to impose upon the credulity of the sick and the ignorance of gaping and amazed friends a belief of the possession of intuitive powers in the detection and distinguishing of diseases. Often without asking a question or touching the patient, they pronounce with the gravity of an oracle, the name of a disease, and without a moment's reflec- tion, direct the treatment. Such a man is considered a miracle of sagacity, while in truthj he disgraces his profession and pollutes the temple of science with the daring and mercenary footsteps of a heartless and unprincipled intruder. By the strict observance of method in your examination, you will not only command the respect of the enlightened physician, but you will secure almost infallibly the confidence of your patients. Than this, no more important step can be made towards the relief of those afflicted with disease. Without it the best directed efforts of the wisest physician will frequently prove unavailing, while with it the most inefficient treatment will often produce the most miraculous re- 8 tults. Indeed^ so powerful is the influence which it exerts over the minds of those laboring under disease, that were I called upon to furnish you with the means of infallibly securing the confidence of your patients, I would certainly and without hesitation recommend to you, on all practicable occasions, to institute a full and methodical ex- amination, There are few minds so stupid or unenlightened as not to feel and appreciate the assiduity and zeal thus bestowed. Nor is your conduct limited in the influence which it exerts exclusively to those afflicted with disease; you see it extending and exhibiting it- self in the most palpable forms over those by whom they are nursed and attended. The care and attention with which your questions are propounded show that you are inspirid with a sufficient degree of in- terest to study the case while the tact and judgment with which you make them bear upon the disease, leave in the minds of all present a highopiniou of your capacity and attainments. Method rigidly adhered to, will serve in a great degree to pro- tect you from many of those faults which are daily committed by those who conduct an examination as it is too commonly done. You "will not petplox and annoy your patients by questions tediously and uselessly repeated, nor will you be apt to forget those that are leading and important. The omission of the latter may lead the physician to an erroneous conclusion, but the commission of the former, with the intelligent patient, will almost certainly prove prejudicial to his reputation. The repetition of a question which has been already answered, cannot fail to excite surprise in the mind of the observing and reflecting patient. Should he consider it the result of a defect- ive memory, he will think unfavorably of your understanding; of inattention, that your thoughts are engaged upon subjects foreign to his case, and consequently that it does not awaken in you that degree of interest which its importance demands; of doubt of the truthful- ness of his first response, you wantonly insult him by intimating the possibility of involving him in a contradiction. Either of these con- clusions will be sure to distract the equanimity of the most apathetic mind, after which it will be not only impossible to secure the confi- dence of the patient but to deduce an accurate or precise diagnosis-. Besides this state of mental irritation thus causelessly occasioned, precluding the possibility of obtaining satisfactory responses from the patient, it is known by every enlightened physician to produce, par- ticularly in diseases, such a degree of turbulent excitement in the functions of the system as to render it difficult if not impossible to ascertain precisely their pathological condition. It is not enough that an examination be conducted methodically. To its success certain intellectual attributes are but little inferior in point of importance. We allude to attention, penetration, patience and magnanimity. To the successful investigation of a case of dis- ease they are absolutely indispensable. In the scale of importance, attention stands perhaps the highest and the most conspicuous. To enable this faculty of the mind to prove signally available, the power to direct and control it should be almost omnipotent. In the analysis of a case of disease, attention should bo steady, unwavering and con- centrated. If remitting or wandering some important feature will 9 escape observation, while it will be impossible to scrutinize it closely under the many diversified phases frequently presented. If not concentrated many useless and irrelevant questions will be asked; others will be repeated and much time fruitlessly expended. But, when this is the case the evil of which the patient will almost always have just cause to complain will be that his disease is not understood. The hurried manner in which an examination is usually conducted even in regard to ordinary diseases, cannot fail to preclude the pos- sibility of a precise diagnosis. When from complication they are difficult of analysis, their exact nature is rarely understood until it is revealed by a post obituary dissection. Such cases instead of con* stituting an excuse for a brief or precipitate examination demand the most undivided and undistracted exertions of attention, as well as a renewed and a more vigorous application of thought. Summon all your energies to the investigation, and no matter how great may be the complication or varied the difficulties which the case may in- volve, if perfectly master of the science of diagnosis, rare will be the instance in which you will find yourselves foiled or defeated. Know- ledge and attention properly controlled and directed, will enable you to decompose into its fundamental elements, the most complicated and embarrassing disease; and one such triumph, after those perhaps superior to you in age and experience have been completely defeated, will prove abundant compensation for the many hours and days of pain- ful solicitude which the practice of medicine never fails to entail upon its humane, enlightened and faithful votaries. The educated physician in whose heart the benevolent and humane feelings sit meekly enthroned, will never compromit the safety of those who may commit their lives to his keeping, by suffering his mind to be distracted by a multitude of considerations foreign to the duties he is called upon to perform. He will be diligent, unwearied and methodical in the attention he bestows upon them, and such a course of conduct will enable him to examine without confusion, the many objects which a case of complicated disease may present to his observation; will prevent him from being imposed on by false and de- lusive appearances; will exhibit them to him in their true light and natural succession. Important, nay, indispensable as close .attention undeniably is to the scrutinising observer in scanning the phenomena of disease, as they are exhibited, it is of itself altogether insufficient to enable you to ferret out their real nature and true tendency. To do this, pene- tration highly cultivated and disciplined is absolutely requisite.—■ Without it attention would bestow its labor in mechanical and stupid amazement. Much would be seen but nothing understood. Not only would the language of disease be unintelligible, but the nicer shades of ssemiology would elude observation. To practice the artof examination with success, not only is it ne- cessary that the manifestations of disease should be observed, but their nature and probable tendency must be interpreted and under-1 stood. This requires not only sagacity but the highest order of in- tellectual penetration. Very often the phenomena follow each other in such rapid succession and make an impression so feeble and tran- / o 10 sient upon the mind, that if they are not seized at the moment they are irretrievably lost. To expect to ponder over them as over the ordinary occurrences of the chamber of disease, would be absurd and preposterous. Their existence must be detected; their nature un- derstood, and if prejudicial, their tendency counteracted on the spot, or they are gone and the life of a human being is endangered if not sacrificed on the altar of professional stupidity. No matter with what degree of accuracy you may observe, without penetration, you would not be able to distinguish the accidental from the regular and ordinary—the subordinate from the leading and cha- racteristic phenomena of disease. The relations which the objects of your attention bear to one another, or the relative degree of their reciprocal influence would not be detected or appreciated. The ef fects of your remedies would be confounded with those of disease, and vice versa: while you would be totally disqualified to distinguish the physiological from the therapeutical action of your medicine's. However steadfastly you may be able to fasten your attention on a case of disease; keen your penetration in detecting the nicer shades of difference in the ssemology; or sagacious, in discovering and foreseeing the nature and tendency of the most complicated morbid actions; these faculties will prove of comparatively inferior utility, unless they are associated with the power of keeping them actively on the stretch for a considerable length of time without fatigue or restiveness. This you will find absolutely necessary: for often will you be called on to listen a tedious length of time to uninteresting and unimportant details: this you must do not only with an un- ruffled temper, but with the most impurturbable composure and en- during patience. Though your'time is not thus taxed, and your in- dulgence is not carried to the utmost pitch of endurance by the general- ity of those laboring under disease, you will always find a restless and impatient temper, a great barrier to the successful prosecution of a minute and protracted examination. Hostile, as it doubtless is, to the best interests of those who confide in your capacity and attainments, no effort should be spared to subdue and eradicate it. Haste or pre- cipitancy in the conduct of a physician, is not only an obstacle in the way of the satisfactory discharge of his duties, but it is positively disreputable, undignified and empyrical. More often does it result from the degrading desire to appear overrun with business thati from the actual possession of more than can be without difficulty or in- convenience attended to- Whatever be the motive, it can never au- thorise you to precipitate an examination. To whatever trouble or inconvenience you may be reduced, it can never be alleged as a le- gitimate excuse for undertaking the treatment of a disease which you have not had the patience to understand. Nor should the poverty of your patient or the revolting privations of his cottage, drive you from his humble habitation before you have conscientiously discharged your duty. Keep constantly in mind that an erroneous diagnosis may involve consequences of the most fearful and disastrous character, and you will be forever deterred from rush- ing, as is too often the case, from the chamber of affliction with the precipitancy of a detected pick-pocket. 11 The qualities of mind just adverted to, will contribute much towards rendering you skillful and successful, but they can never enable you to become honest and humane physicians. To be justly entitled to the distinction these attributes never fail to confer, the spirit of magna- nimity and candor must reign over and be perceptible in all your con- duct. Trick and cunning, management and the grave may conceal your blunders and shield you from the hatred and scorn of a deluded and outraged people, but can never soothe one pang of a wrung and tortured conscience. If dead to shame and insensibie to the stings and horrors of such a remorse as licensed assassination should bring, you may, by address, extricate yourselves successfully from the most perilous and embar- rassing situations, and may continue to float buoyantly and triumph- antly on the sweeping tide of popular favor. But if conscience has not ceased to remind you of your moral responsibility, you must look to your candor and magnanimity for assistance in circumstances of doubt and difficulty. They will encourage you frankly to confess your ignorance of what you do not know, and will enable you to in- timate without blushing, that you do not consider yourselves omni- scient in your profession. Rarely as we see this course of conduct practically illustrated, rest assured, if from pride or selfishness, you should find yourselves incapable of making such sacrifices, )rou are aliens and strangers to the feelings and sentiments of honest or hu- mane men. Do you consider such language harsh and unauthorised? If so, let me ask, Is it honest to delude a patient with the belief that you under- stand his case when you not only doubt, but when your mind is in a state of the most agitating uncertainty on the subject? Would it not be the basest moral infamy, the most inexcusable and atrocious cru- elty to risk the life of a confiding and suffering fellow-being upon the truth of a mere conjecture; the possible validity of a random guess? Indefensible, not to say abandoned and profligate as such reckless and heartless conduct must ever appear in the estimation of humanity and honesty, do we not daily see striking and terrible practical illus- trations of it? Do we not see physicians, rather respectable in point of reputation; yes, diplomatised practitioners treating diseases, of the real nature of which they know as little as did the Alchemist of the art of converting the baser metals into gold, with a fearlessness of consequences absolutely startling? Who will dare deny the truth of this allegation? Who will venture upon the defence of such indivi- duals? Does such an outrage upon public confidence admit of ex- cuse or extenuation ? No, it stands forward in all the harshness of unmitigated crime, without one alleviating circumstance to soothe resentment or propitiate regard. To urge that unadmonished of their ignorance, they rush forward under one of the most fatal delusions to be found in the eventful records of intellectual imbecility, would be a gross libel on the human understanding. There is no delusion but that of sordid interest; no infatuation but the insatiable love of gold. Their souls never felt one virtuous impulse; their flinty hearts were never softened, never blessed with one touch of infirmity; their bosoms seem hermetically closed against every tender impression; 12 they look unmoved upon eyes rolling in agony and swimming in death. In the ordinary affairs of life, it is not uncommon to see the expe- rienced and unprincipled take advantage of the ignorance and impose upon the credulity of guileless and unapprehensive men. This is done with comparative impunity to almost every vital interest. But whenever the physician avails himself of such means to procure ad- vancement in his profession, he should be condemned as an impostor to hopeless exile from the society of his fraternal associates. His duties are multifarious and of a nature delicate and difficult, while his numerous responsibilities are of the most solemn character. If he is, therefore, guilty of no derilection, he must exert the stern cool- ness of the philosopher as well as the forbearance, the self-denial, and be able to make the sacrifices of the Christian. Pride, ambi- tion, self-interest or any other unworthy feeling should never deter you from making such disclosures as are requisite to ensure the safety of those who may confide their lives to your skill and judgment, or to shield your bosom from the barbed shafts of rankling remorse.— When called to the examination of a case that is cause of difficulty or embarrassment to you, think not that you sink in the estimation of sensible or honorable men, by expressing your doubts, or even, if ne- cessary, by confessing your ignorance of its nature. Under such circumstances, never fail to request a consultation; never in a state of uncertainty, venture upon its treatment;never have to make, even to your own consciences, the humiliating concession that your thera- peutic indications have rested, in a single instance, on conjectural grounds. Rational treatment has no other basis than accurate diagnosis. To deduce it from any other source is unblushingly to play the Charla- tan and cruelly to tamper with human life. This is so true that even unprofessional minds feel and understand its force, while the unprin- cipled empyric has recourse to every subterfuge to avoid an illustra- tion of it, Let the physician admi/ that he is not certain as to the exact nature of the disease, and at the same time insist upon its ex- clusive management, with what instinctive horror will the patient shrink from his drags, and with what eagernesss will his friends spring to save him from the poison of an assassin! If the opinion, to successfully treat a disease, it is necessary to understand its nature, were as prevalent with the profession as it is with the public, what an Iliad of misfortunes, to use the language of Demosthenes, would not humanity be spared? In cases of difficulty and danger, should you fearlessly deter- mine to act without having any fixed opinion of their nature, what are the results that may be reasonably expected? Your conduct be- ing, of necessity, either timid and irresolute or rash and inexpedient, human life will be endangered if not wantonly sacrificed. If you act at all under such circumstances, you act on the apochryphal authority of a guess, and jf you happen to act correctly, is it not rather a mira- cle than a probable result? Alarming and unpardonable as such du- plicity evidently is, too often have we occasion to witness most fear- ful exemplifications of it. We see, too frequently, physicians obstin- ately persevering, day after day, in the treatment of cases of disease, 13 in regard to the precise nature of which they cannot give even a plau- sible conjecture. Why is this? What tenable excuse can be alledged for thus pracr rising upon the credulity of the public; for thus wantonly tampering with the springs of human existence? None whatever. Such im- posture is the oti'springof pride'and self-interest; the nursling of ig- norance and illiberality. Rather than hint a doubt, they brave the perils ot the most irrational treatment; rather than shrink from a firm reliance upon their unaided judgment, they expose their patients to the most incredible sufferings as well as to the most appalling dan- gers. Nor is this all. With an inconsistency of conduct, truly mar- vellous, life is no sooner extinct than the disease, which before death was considered intelligible, now becomes mysterious; that which but a few hours before was easy of interpretation has become inscrutable. Permission is asked of the friends of the deceased to make a post obituary examination. For what? To confirm the truth of the di- agnosis previously given and to establish the correctness of the treat- ment previously employed? No; but forsooth, because no confidence is placed in that diagnosis; because they are now curious, when hope has fled, to know what was, in truth, the real nature of the disease to which the deceased has fallen a victim. How any man can un- blushing declare a case of > disease mysterious or unintelligible, of which he has been busily engaged in the treatment for days, and perhaps weeks, when his conduct tacitly implied that he did not so consider it, is to me incomprehensible. When the dissection is made and it is distinctly ascertained that tho disease was neither understood nor properly treated, how does he defend himself before the tribunal of his conscience; how does he shield his bosom from the compunc-. tious visitings of sorrow aiid remorse ? By alledging that he acted in obedience to the dictates of his best judgment? Such is not the fact; it is a base and untenable subturfuge. His judgment was not de- ceived, nor did he listen to its admonitions. It convinced him that he did not understand the disease, but pride and self-interest derffred him from making the important disclosure. It recommended to him the necessity of a consultation, but the fear of its consequences ren- dered him deaf to the advice. Thus you perceive humanity and honesty unite in imploring you to deal candidly and magnani- mously with those who may confide in your skill and judgment. It is a debt you owe to justice, and if a sacrifice, it is one you should never shrink from making upon the altar of public good and private happiness. Unless you prefer the welfare of your patients to the advancement of your personal interest, you can never make safe or sincere physicians. Presenting in your intellectual character the features to which we have in detail adverted, and possessing a knowledge of the science of diagnosis in its present improved condition, you may expect to make some proficiency in the * Art of examining the Sick? But this cannot be done without the strict observance of several precautions which experience has proved to be indispensable. The deceit of pa- tients is not less to be guarded against than the duplicity of physi- cians. From a number of the most diversified motives, there are 1* those who, in order to cheat and betray you, will use every effort and resort to every stratagem. Diseases that have no existence are often feigned, while the most strenuous and persevering exertions are made to conceal those that really exist. Some individuals are prompted to act thus from motives so secret that it is impossible to detect them, while others seem inspired by the mere pleasure of de- ception. Those who feign diseases employ means of precaution so complex and elaborate as to imply the operation of motives of the greatest magnitude and importance, while those who would conceal an existing disease, frequently endure without apparent emotion the most exquisite suffering. To be imposed upon by either would be a- like humiliating and discreditable, and therefore, to avoid a result so compromiting in its character, you will be often required to sum- mon to your assistance all your attention, penetration, prudence and knowledge of your profession, however large and comprehensive. In your intercourse with society, you' will find a numerous class of individuals characterized by great sensibility and a lively and sportive fancy. These, without any design to misrepresent or de- ceive, generally exaggerate most extravagantly. Should they be- come your patients, be upon your guard and make due allowance for the habitual style of their conversation. By some persons the slight- est indisposition is considered a grave arid malignant malady, while the most inconsiderable pains are magnified into the most exquisite pangs. Judge of the grade of their diseases by the intensity of their complaints and you will be led into the commission of the most inex- cusable mistakes. The self-instructed, the mere smatterers in knowledge, men who have in their intercourse with good society, or in desultory reading gathered their information, will often be a source of great perplexi- ty to you. Of this class of individuals 'you will find none more troublesome or difficult to manage than those who are in the occa- sional habit of reading medical works. Generally speaking, they hav^. very high idea of their attainments,Vnd are much more soli- citous to surprize you by their knowledge than to inform you of their sensations. From them a direct and simple response it is almost im- possible to obtain. Their reasoning is substituted for their sensa- tions. When asked how they feel, they will tell you what they think. Be on your guard against deducing your diagnosis from the opinions of your patient, instead of from the facts of his case, as well as against founding your treatment upon what he may think of himself instead of what you may think of him. In connexion with the subject under consideration it should be re- marked that there is a solemn gravity of manner more frequently as- sumed by the quack than the enlightened physician; the object of which is to impress the public with the idea of great professional wisdom, or of a life habitually rigid and sanctimonious. Such deport- ment is unbecoming a man of sincerity and truth; while in the dis- charge of his professional duties it is found to be positively delete- rious. The influence of the mind upon the body, particularly in disease, is no longer a question, and this fact is strongly expressed by the author of Tristam Shandy, when he compares the body and mind to a coat and is its lining. < If you rumple the one, you rumple the other.1 If this gloomy gravity of look to which I have alluded, had no other effect than to impose upon the credulity of the prejudiced and uninformed, I would not pause a moment to comment upon it. But this is not the case. Too often it exerts a most omnipotent and ominous sway over those the unhappy subjects of disease. However well balanced a mind may be under ordinary circumstances, this cannot be preserv- ed under the influence of disease. The power of the imagination in the common concerns of life is not a subject within the pale of con- troversy, and in disease, from the fear of death, it becomes excited, and even over well governed minds it becomes paramount in its in- fluence. It opens the mind to the most absurd impressions; its cre- dulity is so great, that like the stomach of an ostrich, the most pre- posterous and incredulous stories are digested. Nothing appears impossible or even improbable. This is particularly the case with the timid and imaginative. Remedies act under the control of the fancy, and the patient recovers from disease or becomes its victim in slavish accordance with its decrees. This is the reason why, in some instances, empyricism triumphs after science and intelligence have been defeated, and why people have died at the exact time which they themselves had prognosticated. In the examination of such patients particularly, and it would not be amiss in regard to all, you should be cheerful without levity. Let your deportment inspire them with hope, and not depress them with fear. The individual who considers his life in peril will watch your movements and the expression of your countenance with the most searching attention, and your very look, if it .bespeak danger, pro- nounces the sentence which the fancy will rarely fail to execute. I have more than once seen patients grow worse after having been visited by one of these Iscariot visaged gentry, and die much sooner than was anticipated; while I have seen a dignified and con- fident cheerfulness infuse invigorating hope into minds already ex- hausted by the enfeebling influence of fear. Admonished of the sources of deception to which you will be ex- posed, let me insist upon it as a rule from which you are never to swerve, but from the operation of causes binding and imperious in their character, always to examine every case of disease, whether mild or malignant, that may be submitted to your observation, with critical precision. This should be done as if, in every instance, the life of a human being depended upon your verdict. The importance and necessity of it, in manifestly dangerous diseases, need not be en- forced or illustrated. Nor is it a duty less obligatory in regard to those apparently harmless in character. Often when a disease is thoroughly investigated, though unimportant in itself, other latent chronic affections are detected. These, by early and judicious treat- ment, may be very frequently cured or their tendency counteracted, but which, when overlooked and neglected, become irremediable. But such lurking mischief is not to be discovered by simply looking at the tongue and feeling the pulse, together with a few questions general- ly not less irrelevant than they are unintelligible. But as I have hinted it is not always practicable nor is it always 16 prudent to institute a full and methodical examination. There is more than one circumstance which should induce this to be postponed. A- mong these the stage of a disease merits attention. During the pe- riod of a paroxysm it should be declined. Besides the mental agitation of the patient being such as to render him incapable of furnishing you with satisfactory information, the disease is then exhibited in all its violence, and to expect, under such circumstances, to determine the condition of all the organs would be irrational. The fullest informa- tion must be obtained from the friends, while the questions propound- ed to the patient should be few, brief and pertinent. Nor should the treatment be active and decided unless the indications should be so urgent as to render delay dangerous. Under such circumstances we should trust to a mild and temporizing medication. A state of great corporeal debility should deter you from a minute and lengthy examination. The fatigue which would be thus incurred, would more than counterbalance any advantage that could result from the most satisfactory information. Nor should a disposition to or actual sleep be interfered with in order to promote the objects of an examination. An examination which you intend to be methodical should com- mence with an inquiry into the age, sex, passions, habits and profes- sion of your patient; into the condition of his general health; the dis- eases of his past life, as well as those of his immediate ancestors; the pe- culiar effects produced by the medicines that may have been previously taken. Such information may be, very generally, obtained from the friends, and that too before entering the apartment of the sick. When this is possible the opportunity should never be neglected. It will ren- der fewer questions sufficient; the examination will be less protract- ed; much time will be saved, and your patient spared much fatigue. Nor is this all. When you have taken the precaution to possess yourselves of the information to which I have just alluded, previously to being introduced to the patient himself, if managed with address it will impart to your conduct an air of inspired, or at least intuitive knowledge. Seeing that you anticipate his1 answers with a degree of precision to him suprising, he immediately conceives a high opin- ion of your judgement and sagacity; he gives you his confidence, and you thus secure his obedience. Will it be said that this is a cunningly devised stratagem to obtain an ascendancy over the minds of those labouring under disease, un- worthy the dignity of your profession? I cannot believe it. The most punctillious will never regard any means justly obnoxious to rebuke, that contribute to alleviate the sufferings of afflicted humanity. As it conduces powerfully to promote the favorable action of your reme- dies your first object should be to command, if possible, the confidence of your patients. Without it, you can never secure obedience or cal- culate upon a strict compliance with your advice. It is for this rea- son that we treat with so much more success the diseases of our inti- mate acquaintances and friends than those of entire strangers. The minds of the former are more tranquil, because they confide unre- servedly in our skill and judgement; those of the latter are agitated by doubt and suspicion, because they have had no proofs guaranteeing 17 the soundness of the one, or the superiority of the other. The force of this fact was not more strongly felt than expressed by Rousseau> when he said, 'I would prefer coeteris paribus, a physician who is a friend, to one that is a stranger: I have little faith in the medicine of physicians, but I have much in that of friends? While examining a patient, keep your eye steadily fastened upon his face. Thus situated, you will be able not only to determine how far you may safely confide in the truth of his responses; but you will have an opportunity of judging of the motives by which he is actua- ted; the passions that control and agitate him; the condition of his so- cial and moral affections, and the character of his mind, all of which will throw light upon the diagnosis as well as the treatment of his disease. Be choice in the language in which your questions are clothed. By this is not meant beauty and elegance, but precision and perspi- cuity of expression. The words in which they are propounded should be not only those in familiar use, but those, as far as practicable* adapted to the habitual language and capacity of the patient. Your meaning must be clearly and distinctly seen, and if you find it is not> let the question be asked in a different form. While your patient understands one thing and you mean another, it would be absurd to expect from him a rational or satisfactory answer. While apatient is responding to a question, or is giving you a nar- rative of his sufferings, listen to him with the most fixed and stead- fast attention. To act otherwise in the common intercourse of socie- ty would be insulting to a gentleman, but it is especially provoking when addressing those the subjects of disease. Should you betray a restless or impatient spirit, under a tedious or too circumstantial nar- rative, he will conclude, and justly too, that your thoughts are pre-oc- cupied by subjects foreign to his case, or pondering upon those in which you feel a deeper and stronger interest. This disturbs the e- quanimity of his mind and arouses his temper. His confidence in you is withdrawn; your control over him is forfeited, and if the exam- ination is persevered in, the results to which you may expect to ar- rive will be unsatisfactory and inconclusive. Those laboring under disease wish to fix your attention, and to inspire you with interest. What they desire, the disease imperiously demands, and humanity should strictly enforce. In his narrative a patient should never be interrupted, though he may not be as full and as explicit upon some points as you could wish. There are more people in the world like the historian of whom Lord Bolingbroke speaks, who could never give a direct and accurate an- swer to any question in chronology, without commencing with the creation of the world, and passing regularly down to the period of time to which reference was made, than is generally imagined. Of this class you will find a large number amongst those of limited and vulgar education. Unless you suffer them to speak on without in- terruption, they become embarrassed; lose the thread of discourse; occasion them perhaps to commit important omissions and expose yourselves to the inconvenience of having to listen to facts tediously 18 repeated. Should additional information be required, it will not b* difficult to turn his attention again to any particular point. Though these general rules would enable you, perhaps, by their judicious application, to become familiar with the ' Art of examining the Sick? this is a subject so very important, and one too upon which your success will so much depend, that you will, I trust, pardon me for speaking still more in detail. We have informed you that every ex- amination should be full and methodical, but at the same time, you must be reminded that it must be rendered as brief as possible by the pointedness and pertinancy of your questions. To observe a particular order, therefore, you will find indispensable. Suppose, for example, you should ask when introduced to your patient, as is commonly done, 'What is ihe matter with you?"* What response would you ex- pect? As was before remarked, those suffering from disease have a great disposition to give you their opinions, instead of informing you exactly how they feel, and nine out of every ten will therefore respond that their complaint is either bilious, nervous, or that it re- sults from a humour in the blood. Now I ask what have you learned ed from such an answer? What more do you know of the disease than you did before the examination commenced ? Not one word. But suppose you should commence the examination by asking, iIn what part do you experience pain?'' This question is very simple, but it will lead you by a direct route to the object of your search. The answer which you will receive will point you at once to the organ and function deranged. Is not this a signal step in the investigation? Does it not give you an important clue in the further prosecution of your enquiries? Every experienced physician will respond in the affirmative. Much light, however, as this single question will throw upon the case under examination, and much as it, in truth, limits the sphere of your labor, you will find that the inclination of the sick to enlighten you by their opinions is so indomitable as to render it almost impossible to prevent them from indulging in vague and idle conjectures. Nev- er distrusting their anatomical knowledge, they will say it is the stom- ach that suffers when it is the spleen; the lungs when it is the liver. To preclude the possibility of deception, you should direct the pa- tient to apply his hand upon the part of which he complains, and nev- er rest satisfied with simply a verbal answer. Nor, in all cases, will even this be sufficient. You will often fall into the greatest errors should you fail to examine the part yourselves. Neglecting to observe this precaution, one of the most acute and talented physi- cians of this or any other age, recently committed, in the city of Paris, a most indefensible blunder. A female, after having been thrown from a cabriolet, complained of pain in the left side of the chest, pain in coughing, expectoration sanguineous, together with considerable febrile reaction. The cough and sanguineous sputa, pointed to the respiratory organs and particularly the lungs, as the seat of the dis- ease. It is true that the intense pain of the side which was exasper- ated by respiration and pressure, might proceed from a lesion of the thoracic parietes, but the strength and frequency of the pulse, red- ness of the face, great thirst, heat of the skin, and the sanguineous 19 sputa, pointed undoubtedly to a lesion more deeply seated. Percus- sion could not be practised on account of the intense pain of the side, but through the Stethoscope the rale crepitant was dinctly heard. Pleuro-pneumonia was announced as the diagnosis. This conclusion was a rational and scientific deduction from the premises above furnish- ed, but when the side was exposed to an ocular and a manual exami- nation, the whole cotege of symptoms was found to proceed from a fractured rib. The second question should be, according to the dictates of reason and experience, lHow long have you been sick?i This, though a very simple, is an interrogatory more purely analytical than any other that can be suggested. It not only abridges the examination, but its answer discloses a characteristic feature of the disease. Does he respond that it is of recent origin, you learn that it is an acute affec- tion. This knowledge enables you, at once, to dispense with such in- quiries as have reference to chronic diseases, while your whole atten- tion will be engrossed by those of an opposite character. Here then, is a second important step made in the investigation. By barely two questions you have achieved two of the principal objects of an exam- ination. You have discovered not only the organ and function de- ranged, but also that it is acute in character. More than once have I heard a score of questions asked without obtaining a tithe of as much information. Permit me to enforce the propriety of the question to which we have alluded, by illustrating it with an example. Suppose you havo, by the first question, ascertained that the patient under examination la- bors under some affection of the head;—what are the diseases to which that part is subject? They are congestion, meningitis, enceph« alitis, hoemorrhage and ramollissment, which are acute—tubercles, cancer, acephalocysts, osseous, tumours of the cranium which are chronic. In view of this formidable array of diseases, you ask your patient lHow long have you been sick?"1 He responds, but a few hours or days; this answer abridges the examination one half.— The chronic affections no longer engage your attention, and you have now only to determine which of the acute diseases just enumerated, has attacked your patient, If familiar with the science of diagnosis, this will not be very difficult. The signs by which each of them arc to be recognised and distinguished, are, for the most part, obvious and strikingly characteristic. After you havo ascertained the organ diseased and the length of time it has been in that condition, you must determine which of the acute or chronic affections, to which it is subject, has interfered with the integrity of its functions. When you have done this, you will pass to the consideration of all the other'organs of the economy, in order to satisfy yourselves in detail whether or not any of the diseases to which they are liable, has disturbed in any way whatever, their functions respectively. In this view, still supposing the brain the or- gan principally affected, you will, in the first place, take up that organ which is known to exert, the most direct and sensible influence upon it, and which is also the most powerfully influenced by it. The same care and attention should be carried into the exami- 3© nation of the organs secondarily as in those primarily affected. This is a duty imperiously binding upon the conscientious practitioner, for when one organ is seriously diseased it reacts upon others and fre- quently not only deranges their functions, but changes their struc- ture. Such lesions are forever concealed from those who examine their patients in a manner either desultorily or hastily; nor are such individuals ever aware of the presence of any co-existing or concom- itant malady. Such diseases are not very uncommon, and even where they actually exist, should an individual be attacked by an acute affection, which is generally the source of much suffering, he will rarely, of his own accord, direct your attention to his prior but still continuing complaints, as they generally occasion him compara- tively little inconvenience. These, though of more difficult detec- tion, are not, perhaps, of less importance than the complaint by which he has been recently assailed, must be ferreted out by the sagacity of the physician, for they not. only continue progressively to under- mine the health, but they often neutralize or counteract the most ju- dicious treatment and always aggravate the acute affection and ex- ert a decided influence upon its termination. Thus, by overlooking the concomitant diseases, no less than three signal mistakes may be committed. The diagnosis will be wanting in precision;—the treat- ment, though not perhaps irrational, will not be sufficiently compre- hensive to embrace the case; and the prognosis, being deduced from a partial view of it, will be false. Why do we so frequently hear of mysterious cases of disease, and such as the physician has never seen before? Because the science of diagnosis is not sufficiently studied and the 'Art of examining the sick* not generally understood. This occasions the concomitant af- fections, which complicate the principal disease and influence its course and termination, to be overlooked. In truth, a very large ma- jority of the diseases to which humanity is heir, are neither mysteri- ous in their nature or such as have never been heard of before. This you will find to be no exaggeration if you make yourselves masters of the science of diagnosis and accustom yourselves to examine in every instance, with close, scrupulous and unfaltering attention all the organs of the economy in regular succession. This, I must re- peat, is your bounden duty. Nothing less will be considered a faith- ful redemption of the pledge which you this day tacitly make; satisfy the just claims of suffering humanity; vindicate the confidence which will be reposed in your skill and judgment, or acquit you before the tribunal of your own consciences. Were we to pause here we should not have given you a sufficient idea, of the importance of thoroughly understanding the 'Art of ex- amining the sick? Cases of disease occur in which you will be able to derive but little assistance or co-operation from the patient. These are chiefly met with in those who labor under a destitution of some one or more of the senses. Such are the deaf, dumb and blind. To lay down particular rules by which you are to be governed in the in- vestigation of their diseases, would be impossible. They must grow out of the circumstances of each particular case. By signs and ges- tures you may learn much, but you must rely upon your sagacity and judgment to enable you to make an advantageous use of them. 21 There are cases of disease in which you will not be able to lay even signs and gestures under contribution, nor to obtain any assis- tance whatever from the patient himself or the knowledge of his friends. Such persons are usually found in a state of insensibility, and the physician will have to rely exclusively upon the accuracy of his acquaintance with the science of diagnosis, and the strength and acuteness of his powers of reasoning. The difficulties which such cases involve, will be more sensibly felt by an illustration. A stran- ger, for example, is found in his room a few hours after his arrival at a hotel, in a state of insensibility and unconsciousness. He is a man of robust frame, the trisplanchnic cavities are largely developed, and he appears to be about sixty years of age. His face is of a deep red or livid color; the temporal and carotid arteries pulsate with energy; the pulse is strong and hard; he foams at the mouth; respiration is embarrassed and stertovous; palsy has invaded one side of the body, and vomiting, together with involuntary dejections, have taken place. These are the data from which you are to reason, and I ask you what is the disease under which he labors? The most prominent feature of the case is unconsciousness. The inquiry of the physician should be, therefore, what are the diseases in which this phenomenon is ob- served? They are those of the heart, of the lungs, and of the brain. You now ask yourself,, is it one of those to which the heart is subjectt No;, because the patient was in good health a few hours before he was discovered in a state of insensibility, nor is there any derangement of the circulation, such as characterize affections of that organ* Is it syncope? No; for the face, instead of being pale and exaaguious, is deeply flushed, while the pulse is strong and hard. Is it asphyxia? No; for although the respiratory and circu- latory functions are embarrassed, they still continue,, while the pa- tient has been exposed to the action of no cause capable of producing; that disease. From this analysis, having discovered that the affec- tion under examination is seated neither in the heart or lungs, you are convinced it must be one of those to which the brain is subject- Although you have now detected the organ affected,, you must recol- lect that the diseases of the brian are numerous. These have been enumerated. Is it one of its chronic maladies? No; for the patient was very recently in a state of sound health. .Being acute, there- fore, you have now to determine which it is of the four or five of the acute diseases that attack the brain. Is it congestion? No; for that is a general disease and this is characterized by local phenome- na. Is it arachnitis? No; for that disease is also general while this has not pursued the course of that affection. It must, therefore, be either ramollissment or effusion* The former it cannot be; for though an acute disease, it never attacks so suddenly nor is its march so ra- pid as has been that under consideration. We, therefore, declare it to be cerebral hoemorrhage, and this opinion is sustained by ^the fact that, no other disease of the brain is so sudden in its attack. The seat and nature of the disease are now determined, but still' the diagnosis is not sufficiently minute and precise. The patient is hemiplegic on the left side of the body; therefore the hoemorrhage occupies the right lobe of the brain. The hemiplegia is complete* 32 therefore, the hoemorrhage is not only in the right lobe, but it ex- tends from the anterior to the posterior part of it. Thus you per- ceive that an acquaintance with diagnosis and your powers of reason- ing, will enable you to analyze a disease, under the most difficult and unfavorable circumstances, into its most simple rudimentary ele- ments ; to diagnosticate not only its seat and nature, but also its ex- tent with a certainty and precision almost mathematical. If, during your first visit, you have been able to determine the seat, nature, extent, and probable course and termination of the disease, a full and detailed examination will not be required afterwards. A few brief and pertinent questions will then be abundantly sufficient. In regard to foreseeing the termination of a disease, others, as well as myself, have found it of the greatest possible advantage to acquire a habit of anticipating the condition of a patient before visiting him. For the purpose of correcting the errors of judgment, your precon- ceived opinion should be compared with the circumstances of the case as they actually exist. This habit, actively and zealously cultivated, will enable you, ultimately, to acquire such a degree of foresight as would appear to you now almsst miraculous. In truth, I know of no other means so well calculated to render you proficient in the art of prognosis. In closing these didactic remarks, suffer me to guard you against an error too frequently committed even by liberally educated and en- lightened physicians. I allude to the habit of visiting the sick near- ly about the same hour every day. Diseases are not always regular in the course they pursue, and, indeed, they are sometimes so remote from it as to render it impossible, for the most experienced phy- sician, to judge what will be their probable character a few hours hence. If, therefore, the hour of your daily visit is not frequently changed, it will be out of your power to see such cameleon affections under all their changing aspects. Doubtless it would prove highly conducive to the interest of those laboring under disease, were it pos- sible for the physician to give them his personal attention during the whole period of indisposition. This, however, it would not be less unreasonable, except under extraordinary circumstances, for the pa- tient to demand, than impracticable for the physician to render. By strictly observing to change judiciously the hour of your visits, the necessity of this will be not only signally diminished, but it will com- bine, to a considerable extent, all the advantages of uninterrupted personal attention. Gentlemen, I owe you an apology for having, at this time, taxed your patience with a discourse so protracted and so purely didactic in its character. 1 throw myself upon your generous indulgence, plead- ing no other excuse than an earnest desire to be of service to you up to the very last moment of our connection. That moment has now arrived. The ties which have bound us together in our respective capacities of pupils and preceptors, must now be rent asunder. We 6end you forth into the wide world of adventure and enterprise, where you will need all your prudence, wisdom and forecast to ena- ble you to elude the fiery darts of temptation that will fall in showers around your integrity, and to extricate you from the dangers to which 23 * your characters will be exposed from the envy, hatred and malice of your enemies. Day after day increase your stock of knowledge; let your conduct be regulated by the nicest sense of honor and the truest and noblest sort of pride; keep your consciences free from reproach, and you may bid stern defiance to the fiercest assaults of the one as well as the most insidious approaches of the other. With rectitude of principle and enlightened capacity, firmness of mind and tenacity of purpose, you may, with confidence, engage in the busy and perplexing scenes of life. Thus fortified, the treachery of pretended friends and the machinations of open enemies may cripple your noblest exertions, but cannot defeat them; the sphere of your usefulness may be circumscribed but cannot be obliterated; your happiness may be impaired, but you cannot be rendered miserable; your hopes may be deferred, but they cannot be extinguished; you may be made to despond, but you cannot be reduced to despair. Go, then, AiUMNi of the Medical College of Ohio, opulent in the means of ensuring the proudest success; may fortune smile upon your efforts; may Heaven bless your schemes of honest enterprise; may you reap the plentiful harvest of honor, fame and emolument, which you so richly deserve. Farewell! I #