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  1871


  MEIGSi

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ADDRESS
DKUVERKl) HKPORK THE
PENNSYLVANIA HOSPITAL,
OCCASION OF THE OPENING OF THE NEW LECTURE
          AND OPERATING ROOM,
JANUARY 9th, 1869.
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By  J. FORSYTH  MEIGS, M.D.,
     ONK OP THK MEDICAL STAFF OF THE HOSPITAL.    1
      PHILADELPHIA:

LINDSAY & BLAKISTON.

           1871.
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TO  THE  READER.
  I have been attached to the Pennsylvania Hospital
for thirteen years, as one of the attending physicians,
and I lived in it  as resident  physician from March,
1838, to  March,  1840.  I  know it therefore within
and  without, and I venture to take, with  the full
sanction  of the Managers, and of my colleagues  of
the Medical Staff', this  method of calling the atten-
tion  of such Philadelphians  as may chance to read
this note, to the financial condition of the institution.
  This hospital  is not the  rich  institution which
many persons ignorantly suppose it to be.
  During the last official  year its income  from en-
dowments was $36,462.66.  Its expenditures for the
city hospital reached the  sum of $53,043.50.  The
difference between its income and expenditure was
made up by casual subscriptions, continued only for
a certain length  of time. Its income, therefore, is
uncertain.  But not only is it uncertain, it is insuffi-
cient.
  The steward of the hospital  is obliged to use a
close  economy as to the number  and wages of the
nurses, and  other domestics, and  in  regard  to the
quality and mode of preparation of the  food, which 
9
ought not to be necessary.  And  how is this to be
remedied ?  Only by a more liberal endowment.
  Some persons object to the management of the
affairs of the institution in certain particulars, and for
this reason lose  their interest in its growth and well-
being.
  But even granting that there may be points in its
management open to criticism, is that a reason why
its past and present great services to  the sick and
wounded poor should be forgotten ?
  Since the year 1752 it has received within its wards
87,666 patients, of whom 53,640 were poor—unable
and not asked to  pay one stiver for their board or
medical treatment.  During the last official  year it
received 2094 sick and wounded, and of these 1738
were poor.
  What an array  of poverty, and misery, and suffer-
ing does not this  simple  statement bring up before
the imagination;  and what a divine  charity must
that be which has lodged and  fed and bound up the
wounds of this multitude of the  poor.
  With such a  record  as this  before him, need any
charitable person  fear to  give or bequeath to this hos-
pital, the  means  of improving and extending  its
accommodations  for the relief  and comfort of the
sick and wounded?
                            J. Forsyth Meigs.
  September 25th,  1871. 
ADDRESS.
Gentlemen:
  My  colleagues  of  the  medical  staff of  this
hospital have  done me the honor of inviting me
to make an address, on the occasion of opening for
public use, this new and commodious operating and
lecture room,  the  erection of which has been ren-
dered necessary by the growing wants of the.house,
and  of the  system of  medical  education   of  the
present day.   I accept with pleasure this agreeable
duty, and venture to  hope that  the theme  I  have
chosen may not prove uninteresting  to those who
grace the occasion with their presence.
  My subject is  one towards which  the thoughts
flow naturally when we consider the  nature of the
event which has brought us together this day:—the
dedication, so to speak, of this room to the purposes
for which it has been built.
  For what, then, has this room been built?  Has
it been erected to serve as the theatre for the various
operations inevitable  to  a great hospital like this ?
Yes.  Was it built to serve this purpose alone ? No. 
4
For what other use is it intended ?  Its other pur-
pose is to further the development  of what I con-
ceive to be one of the grandest utilities of a great
hospital, the proper education of young men for the
vocation of the physician.  I believe, and I do not
hesitate to express  my  belief, that, in  connection
with the proper treatment of the  sick in a hospital,
one  of the most  beneficent uses of such an insti-
tution is the aid which it can and ought to give in
propagating a wise system of medical education.
By such a management two grand results  are ac-
complished.   All is done  by the  institution that
the best and purest charity can effect for the indi-
vidual sick within its walls, whilst by fitting young
men for the difficult and important office of the phy-
sician, it radiates from  its own  narrow centre, to
the  vast mass of  suffering  humanity  beyond  its
walls, a knowledge and experience of the best meth-
ods  of  treating wounds and diseases, which  is of
simply incalculable value to the public.   I know well
that there are  some benevolent and tender spirits,
to whom the idea of making anything like a use of
the sick as a means of teaching medicine, savors of
something harsh and revolting.  But to such as have
this very natural and proper fear, I will say that no
well-trained and conscientious medical officer  ever
forgets that his first duty is  to the individual sick 
                        5
man intrusted to his charge, and that he is bound in
honor and charity to allow no ulterior object to work
detriment to him.  In all hospitals there are many
cases which  can, without  danger  of  injury,  be
brought before a medical class.  Most of the patients,
when the matter is properly and kindly represented
to them,  make  no objection to such a procedure.
Some rather enjoy it, and gladly lend their mite to
the common good.  Moreover,  it seems but right
that those who are fed  and housed, and furnished
with all the means and advice  necessary to their
medical  treatment by  the public,  should  make
this moderate return of assisting, for the public,
in the  necessary  education  of competent  medical
men.  Let it not be forgotten too, that this  de-
monstration  is never made  to  a promiscuous,  or
rude, or gaping public  audience, who might  assist
at such  a spectacle from mere vulgar curiosity.  It is
made only to those who belong to the same vocation
or guild as that to which belong the surgeons and
physicians of the house, and  but for whom this
hospital could not exist, and who,  themselves, but
for like opportunities in the past, could not have had
that exact knowledge and experience whereby these
very patients now profit.
  My subject then is to  be clinical teaching, viewed
first in its relation to the early history of this hospital,
                        l* 
                       6
and secondly, in relation to the paramount impor-
tance of this matter to the public, and to the students
of the complicated and difficult science of medicine.
  In comparing the present with the past, it is  in-
teresting to know that the Pennsylvania Hospital,
from the first opening  of its wards to patients, was
to play a very important part in the clinical education
of the medical students of this city.  The proof of
the correctness of  this statement is to be found in a
small pamphlet  printed in  Philadelphia  in 1817,
which  gives " some account  of the  Pennsylvania
Hospital from its first rise to  the beginning of  the
fifth month called May, 1754."  It  is there stated
at page  49, that  "about this time (1752)  all  the
physicians and  surgeons, who  were contributors,
were consulted, in order to form some rules relating
to the choice, admission, and conduct of the practi-
tioners,  and after sundry  meetings  the  following
were prepared and agreed to,  at a general meeting
of the  contributors."   Amongst these rules the first
sets forth that " the managers  shall choose yearly six
practitioners in  physick and  surgery, to visit  and
take care  of the patients in  the said hospital,  and
the other practitioners (who are at this time mem-
bers of the corporation) shall have  the privilege of
attending and observing the practice of those chosen
for the  service  of the year."  Here  at  the very 
7
outset  of its career, we  find the whole authority of
the board of contributors providing that the hospital
should be used, not only for the good of the sick and
wounded in the house, but that the opportunities it
might  afford  as  a school of medical experience,
should be extended to all the members of the board
of contributors who were practitioners of medicine.
  Again, in the sixth rule it is laid down that "each
apprentice or other student the practitioners shall in-
troduce to see the practice of the hospital, shall pay
an English guinea, or thirty-four shillings, current
money, per year, to be laid out in medicines, or such
other matters as the managers think proper." Here,
then, is provision made that students should be al-
lowed  to see the practice of  the house, or, in other
words, be taught clinical medicine.
  I find still other  proofs that this institution has,
from a very early period, been active in  lending its
aid to  the cause of clinical  instruction.  In an ad-
dress on the occasion of the centennial celebration
of the founding of the  Pennsylvania Hospital, by
Professor George B. Wood,  delivered in the  year
1851, the orator states  that,  " so early as 1766, Dr.
Thomas Bond proposed to deliver a course of clinical
lectures to the students,  and,  the proposition being
approved by the managers, commenced  in Novem-
ber  with an  introductory lecture, which was  so 
8
 highly thought of by  the board that it was copied
 into their minute-book."   " From that time to the
 present," Prof. Wood continues, " clinical  lectures
 have  been given  more  or  less regularly at  the
 hospital, either in the form of remarks by the bed-
 side, as the students were conducted through the
 wards, or when they have been too numerous,  as of
 late, to be thus  conducted,  by regular lectures in
 the amphitheatre, to ..which the patients were  con-
 veyed."  The centre building of the hospital, in the
 third story of which is the old operating and lecture
 room,  which we  vacate  to-day for  this so much
 larger and more convenient one,  was not finished
 until the year 1805.
  Thus, gentlemen, we are bidding  adieu to-day to
 a room which has served as the  arena of clinical
 instruction in this house  for a period of upwards of
 sixty years.  That room must have heard the voices
 of many  of the most  distinguished surgeons and
 physicians of this country.  There must have taught
 the eloquent Rush, who continued his connection with
 the hospital up to the year 1813.   Here also taught
 Wister, Physick,  the two  Bartons, Coxe, James,
 Dorsey, Hartshorne, Otto, Colhoun, Parrish, Thos.
 T. Hewson, the father of my present able colleague,
the two Moores;  but,  gentlemen,  I have not the
 time to  mention the names of all those who, for the 
9
pure and  unselfish  love of their art, have wrought
strenuously, patiently, and many so wisely for the
good of the patients in the house, and of those still
more  numerous sick and  suffering, who were to be
intrusted in all parts of our widespread land, to the
skill and knowledge which the students here taught,
might carry forth into the distant regions  where
they were to pursue the medical vocation.
  It is pleasing,  in glancing backwards  from the
moment  of to-day,  to  know that the first mover in
the foundation of this, for young America, old and
time-honored institution,  was  a physician; that, to
the medical body of this  city, in the year 1751, we
owe the  germ of this,  one of the oldest charitable
corporations in this great and  powerful nation.  In
Bigelow's late edition of Franklin's Autobiography
I find, at page 281, the  following passage,  which
clearly sets forth the fact I have just stated.  Franklin
says:  "In 1751 Dr. Thomas Bond, a particular friend
of mine, conceived the idea of establishing a hospital
in Philadelphia (a very beneficent design, which has
been attributed to me, but was originally his) for the
reception  and care  of poor sick persons, whether
inhabitants  of the province or strangers.   He was
zealous and active  in endeavoring  to  procure sub-
scriptions for it, but the proposal being a novelty in 
10
America, and at first not being well understood, he
met with but small success.
  " At length he came to me with the compliment
that he found there was no  such thing as carrying a
public-spirited project  through without my  being
concerned in it.  For,  says he, 'I am often asked
by those  to whom I propose subscribing: Have you
consulted Franklin"upon this business? And what
does he think of it?  And when  I tell them that I
have not (supposing it rather  out  of your line) they
do not subscribe, but say they will consider of it.'
I inquired into the nature and probable utility of
his scheme, and receiving from him a very satisfactory
explanation, I not only subscribed myself, but engaged
heartily in the design of procuring subscriptions from
others. Previously, however, to the solicitation, I en-
deavored to prepare the minds  of  the people by
writing on the subject in the newspapers, which was
my  usual custom in  such cases, but  which he had
omitted."  The account goes on to describe the man-
ner in which Franklin obtained a grant of money
from  the Assembly, but it is not worth  while to
continue  the quotation any further, as I  have given
you enough to show where the idea of this noble and
useful institution took its birth.
  This all occurred many long years ago.  It is one
hundred  and seventeen years since  that plain and 
11
sober physician,  with his broad-brimmed hat, his
knee-breeches, buckled shoes, and buff-colored coat,
came to him, who was to leave behind him one of
the most famous names and reputations as philoso-
pher, patriot, and statesman  which this country has
produced.
  It was only eight years before this, 1743, that this
city, which now boasts of a population of over 600,-
000  souls, contained  only 10,000 inhabitants.  One
year before this time, one hundred and eighteen years
ago, persons were living  in this then small city  who
remembered when its site was a forest;  the first-born
of the city was then  a man of sixty-eight years of
age; and at that time bears, wolves, and wild turkeys
were shot  within  eight  miles  of the State-house.
At that time, too, the great city of Baltimore  con-
tained less  than fifty houses.
  Three  years  before Dr.  Thomas Bond went  to
Franklin to solicit his aid in founding this hospital,
on  the 20th of September, 1748, Franklin wrote to
a friend in New York, "I  have retired to a more
quiet part of the town, where I am settling my old
accounts, and hope soon  to  be quite master  of my
own time, and no longer, as the song has it,' at every
one's call, but my own.'"  And where, think  you,
was this more retired part of the town ? It was at the
southeast corner of Second and Race.   His garden, 
12
Parton  says, probably extended  to  the Delaware,
distant not more than one-eighth  of a mile.   It was
not difficult, the biographer goes on to say,  for him
to indulge his  passion for the water, in  which he
used to spend an  hour or two every fine summer
evening.     ,
  Franklin had not yet stood in the cock-pit  in Lon-
don, in the presence of thirty-five ni embers of the Privy
Council, with the Lord President Gower at their
head, with Lord North,  Burke, the Archbishop of
Canterbury, Lord Shelborne, Dr. Priestley,  Jeremy
Bentham, and many other lookers-on, to  abide for
many hours what Bentham called the  "pelting of
the pitiless storm" of  Wedderburne's most dis-
graceful and outrageous abuse and invective, a scene
of villanous treatment of a messenger  from a dis-
tant people which prompted Horace Walpole's epi-
gram upon Franklin and Wedderburne:
        Sarcastic Sawney, swol'n with spite and prate,
        On silent Franklin poured his venal hate ;
        The calm philosopher, without reply,
        "Withdrew, and gave his country liberty.
  Franklin had not proved, by his famous experi-
ment with the kite, the identity of lightning with the
comparatively feeble and puny phenomena of elec-
tricity, obtained by rubbing various bodies with silk,
or from the Ley den jar; nor had he yet won over 
13
by his admirable  diplomacy,  by his original and
manly independence of character, his wonderful tact,
and, above all, by his commanding intellect, the court
of Louis Seize and Marie Antoinette to the cause of
his feeble and struggling country.
  This was before the day of Braddock's expedition
and defeat, when the site of the great manufacturing
city of Pittsburg, with its population of over 80,000
souls, was marked only by a French fort.   In those
days, men not far from this great city, carried arms to
the field and the church, that they might sow  their
grain and worship God, and, at the same time, guard
their lives and property against the attack of the In-
dian, whom they were slowly thrusting back from the
hunting-grounds he had inherited from his ancestors.
And, gentlemen, how painful is the thought that the
stronger race seems always, in history, destined not
to  absorb and  civilize,  but to  crush out of exis-
tence, the weaker races with which he  comes in
contact.  What Dr. Bushnell calls the out-populating
power of the Christian stock seems  nearly always
to end in the destruction of a Pagan people.
  In  looking over a volume  of the minutes of the
Common Council of this city, from 1704 to 1776, to see
whether there might be any reference to the hospital
by  that  b6*dy, I found nothing connected with this
institution;  but  was amused  to find that about the
                        2 
14
time it was established, this good city employed and
paid a public whipper.   At a common council held
the 8th day of January, 1749, the high sheriff, Richard
Sewall, in his account of sundry fines received, &c,
                    £ s. d.
claims a drawback of 8 1 5 paid for a suit of clothes,
hat, shoes,  stockings, &c, for  Daniel, the whipper,
paid by order of ye magistrates.  At the same meet-
ing was read the petition of Barbara Morgan, setting
forth that  she  was convicted  at the last  Mayor's
Court of felony,  and  has received  the  corporeal
punishment adjudged  her;  that she is much ad-
vanced in years, is so very poor  that she is not able
to pay even the costs of prosecution: the board there-
fore  thought fit to  remit the fine  due from  said
Barbara Morgan to the Corporation.
  So  that  this  institution, in which we are now as-
sembled, rose into life in the days when the red Indian
called a large part  of the  State of Pennsylvania his
own; at  a time when the hold  of France on this
continent had not yet been broken; whilst our fore-
fathers were still  loyal  subjects  to  the  crown of
England; and  whilst the public whipper  still ex-
ercised his functions  in this city of brotherly love.
  And now, gentlemen, after  these remarks,  upon
the connection of this hospital with clinical teaching
from  its  earliest history,  I pass  on to  the second
division of my  subject; a consideration of the para- 
15
mount importance to the public, and  to medical
students, of that branch of medical education for the
development of which this room has been erected.
  Since hospitals cannot be carried on without phy-
sicians and surgeons, any more than life insurance,
or war by land or sea; since municipalities require
their physicians for the prison, the dispensary,  and
the  almshouse; since the ship of commerce never
goes to sea without her surgeon or  medicine-chest,
and since every family in the community must have
its doctor, medicine-chest, or quack-salver, it is plain
that the medical profession is one of the necessities
of society.   In  spite  of the  ridicule of wits  and
poets, and of some of the  so-called wise  people of
society, in spite of homeopathist and hydropathist, it
is plain that physicians and surgeons must be had.
The soldiers and sailors of Grant and Farragut, and
of Sir Robert  Napier, would have marched into the
pestilential swamp, and  into the heat and storm of
battle, with less of the sublime courage they so often
exhibited, had they not known that trained medical
officers stood  ready, with ambulances and medical
stores, to succor them in case of need.  How could
the  great  life  insurance  companies,  with their
millions of dollars of capital, continue their business
without  their  skilled  medical examiners ?   What
husband, with any natural love for his wife,  will 
16
allow her to enter  upon the pangs and dangers of
childbed, without proper provision  made to secure
the services of a good accoucheur ?   What mother
will face the perils of teething, scarlet fever, croup,
and  the thousand  ills of infancy and childhood,
without the aid of her family physician?   When
cholera, or some other epidemic, like yellow fever or
typhus, falls upon a community, to whom does the
public look but to the medical body?   The whole
public, therefore, and not merely the managers and
medical staff of this hospital, are interested in the
erection and proper use of this room, which we
open to-day for the benefit of the public.
  All the best writers on medicine, and the merest
common sense, too, declare that clinical or  bedside
teaching ought to constitute an integral and impera-
tive part of the curriculum of all medical schools.
  Why, is it not plain that a student who refuses or
neglects to employ the  opportunity  of acquiring
that  personal  acquaintance  with disease, which  a
large hospital affords, under the guidance  of men
trained by  long  experience,  and with his  great
objective point, the sick man,  before him, must at
last, teach himself clinically, groping in the  dark
and alone, at the bedside, and toiling painfully for
years to acquire what might have been learned in as
many months.  No; no  man should  be allowed to 
                       17
prescribe. for  the  sick  and wounded until he has
touched and handled  the  sick, in the presence of,
and  aided  by, men older than himself, who have
themselves had the training which experience, per-
sonal and taught,  can alone give.   Health and life
are possessions too important to the individual and
to society, to be intrusted  at haphazard to any man
who  may go about offering to take charge  of things
so precious.   No  honest  and  clear-thinking man
would wilfully jeopard the serenity of his own soul,
by stepping forth from a  series  of mere didactic
lectures  or readings, on  the  theory of  medicine,
surgery, and obstetrics, to face the terrible responsi-
bility of health and life, until he had made himself
in some  degree  familiar, by direct contact, under
proper instruction, with those awful realities amidst
which his work is to  lie,  wounds, disease, and the
travail of childbirth.
   A man might as well expect to become a proficient
on the piano or violin, by the mere study of the laws
of sound, as to become  a  ready and skilful  practi-
tioner of medicine by the  mere study  of anatomy,
physiology, chemistry, or the theories of practice,
surgery, obstetrics, and materia medica. The study
of Tyndall on Sound never made and never will make
a Paganini, or  a Henri  Herz, a  Malibran, or  a
Jennv Lind.   The fingers and the  larynx and the
                       2* 
                       18
auditory nerve, must all be educated by Jong and
patient clinical  study,  so  to  speak, before these
organs and the  nerve  centres which govern them,
can be brought to that wonderful state of perfection
which habit and use alone give, whereby what were
at first slow and awkward efforts of the will, directed
to each separate sensation and movement, become at
last the rapid and certain perceptions and resultant
movements, which are accomplished by what seems
to be an automatic process.  Or, if we wish a further
and simpler illustration  of the necessity of practice
to effect the development of the faculties, what need
we more than the  simple act of reading a printed
page.  All of  us, I am sure, can recollect the time
when the alphabet, and afterwards the words, incor-
rectly  called  in nursery language  " easy words,"
entered into our consciousness only amidst tears  and
fears.  No philosophic theory of the laws of form, of
the line of beauty, or of the analysis and synthesis of
colors, ever made a painter or a sculptor. No study
of the correlation of forces ever made an intelligent
and successful  iron-master.  No comprehension of
the convertibility of heat into motion, or of  motion
into heat, ever taught an engineer how to start or to
arrest his majestic and ponderous locomotive or iron-
clad.  A  man  might know Tyndall on Sound and
Rush on the Voice from title-page to  finis,  and yet 
                       19
be no nearer the marvellous  power of a Grisi or
a Lablache than you or I,  whose larynx has never
been trained to that kind of work.
  Medicine  is taught and learned to make practi-
tioners, not mere medical savants.  You who are
come to this room to hear clinical lectures upon, and
to see with your own eyes, the practice of medicine
and surgery, to witness  operations, and to observe
the method of analyzing cases of disease, come here
not to study a  speculative philosophy, like Psy-
chology or Metaphysics.  Your  object  is to study
your profession in its relations to  executive action,
to practice.
  Medicine  has  been  defined,  of  late years, as
being  both  a  science  and  an  art—a  science,
inasmuch as it  consists of a large body of exact
knowledge,  in the  form of Anatomy,  Physiology,
Chemistry, and Materia  Medica;  an  art,  for the
reason that this exact knowledge is to be applied to
practice in the form of  the different branches called
Surgery,  Practice   of  Medicine,  Obstetrics,  and
Therapeutics.
  The simple truth is that Medicine, as you and I
have to study and use it, is a practical science, and,
like all other practical,  as opposed to purely specu-
lative science, necessarily involves a theory.   If we
agree to call any branch of human knowledge an art, 
                       20
when viewed in relation to its practical application,
and a science, when viewed in relation to the theory
which that practical application supposes, no one can
object, and all the world can  understand the terms.
A very simple illustration  will show my  meaning.
You place your ear over the heart of a healthy man,
and  hear certain sounds.  The scientific side of
medicine  describes  the exact character  of those
sounds, and explains their causes. Here we have the
scientific description and theory of the physiological
sounds  of the heart.  Again,  you  place your ear
over the heart of a man who  consults you  about his
health, and hear certain sounds more or less differing
from  those of the healthy heart.  Pathology, the re-
sult of long and laborious  study of disease, as physi-
ology is the result of long  and laborious study of the
healthy organism, describes in accurate language, the
various characters of these new sounds, explains their
causes, and thus gives the disease which has produced
them,—and here we have the scientific side of pathol-
ogy.  And now comes the art side of medicine.  You
know that  this  man is sick, and  you  apply this
knowledge to practice.  You make the  diagnosis,
announce the prognosis,  and  then the  treatment
and lastly, you receive, if the  patient has read his
Bible, and recollects that the  laborer is  worthy of
. his hire, a proper fee or honorarium, and thus at last 
                       21
we find medicine'ranged amongst the bread  and
butter sciences.
   Medicine is, therefore, both a science and an  art,
and like all other  branches of human knowledge
that are practical as well as scientific, can be acquired
only by patient  study  of its  subject or object,  the
sick man, or by what is called technically, observa-
tion.   To become skilful practitioners  of medicine,
whether as Physicians, Surgeons,  Obstetricians, or
Specialists, as Aurists, Oculists, or Orthopedists, you
must  cultivate the habit of observation—you must
become good observers.  It has often been said that
a thoroughly good observer is  a rare  thing in  this
world; in  other words, that many  men  go about
with eyes, yet not seeing; with ears, yet not hearing;
with brains, yet not thinking. And is not this true ?
Do not some men seem to stumble through  life as
though in a dream, or half-asleep, not apprehending,
not feeling, not seeing  what is going on in this busy
world on every side of them.  This complaint of the
want  of good observers in medicine is founded in
fact, for in the first place, nature does not  create
many men  such as Hippocrates, Sydenham, Jenner,
Laennec, or Louis, men endowed at  birth with the
mental and physical  qualities which fitted them for
that  wonderfully wise and  accurate  observation,
which has stamped their names on  the  roll of fame 
22
forever.   But I believe that whilst all  men  cannot
hope to  attain to the rare proportions of  those
I have just named, we all can cultivate, by careful
and systematic and  continued application  at the
bedside, a degree of accuracy and perfection which
has  no limit but that set by  opportunity and du-
ration of health and life.
  Let us, gentlemen, in order to have a clear under-
standing of the nature of the study requisite in the
medical  vocation,  consider what  are  the  special
faculties of the mind necessary for the purposes of cor-
rect medical observation.  By doing this you will the
better comprehend what lies before you,  in what way
you may best train yourselves into accurate observers.
If you determine now  what particular  faculties are
the  most important for the study and practice of
.medicine, you may at the  present moment, here
in this new clinical room, resolve to set to work to
develop  by use,  by  training,  the  special faculties
which you  will require in  your future lives.  If a
man, with a view to winning a boat race, or a cricket
or base-ball match, or for the purpose of pummelling
and being pummelled, in a prize-ring,  will go into
training for weeks or months—living on a diet ab-
staining from tobacco and alcohol, and all and every
kind of dissipation, sleeping so many hours, running
his two  or three miles a day—why shall not a stu- 
                       23
dent of medicine determine  to  put  himself, at the
outset of his studies, into  a sort of training for the
great game of his  life, a contest  with disease and
death ?
  I am about  to cite to you the division of the
faculties of knowledge laid  down by Sir William
Hamilton, of Edinburgh,  him who has been called
the prince of philosophers.   This citation from a
great work on metaphysics may seem, at first view,
strangely out of place in a lecture  upon  clinical
medicine, but I have no fear that you will think the
quotation either tedious, pedantic, or far-fetched, if
you will only bear in mind that these faculties are,
so to speak, the mental and  physical tools, by the
proper  use of which  you are to have the power to
become able and successful physicians.
  The faculties of knowledge which  are used in the
acquisition of knowledge, whether a knowledge  of
tumors or phthisis, fracture, cut or contusion, croup
or convulsions, chemistry, materia medica or thera-
peutics, painting or sculpture, architecture or agri-
culture, pin-making oi» bread-making, or any other
practical human science or art, are divided by Ham-
ilton into six categories:
                f External=Perception.
1.  Presentative j Internal= subconsciousness.
2.  Conservative=Memory. 
24
                r Without Will=Suggestion.
3.  Reproductive jWith Will=Reminiscence.
4.  Representative=Imagination.
5.  Elaborative=Comparison—Faculty of Relation.
6.  Regulative=Reason—Common Sense.
  Let us now consider how these various faculties
are to be employed in the study of clinical medicine.
  To observe a case of disease accurately, nearly all
these faculties  of  knowledge  thus classified by
Hamilton, must be brought into constant play; we
require,  of  course, that one of  the  presentative
faculties  called the external or perception, for we
must assuredly use the eye, the'ear, and the touch in
every case that comes before us.   In many we shall
need also the sense of smell.  That of taste is fortu-
nately not so necessary as  formerly in  the investi-
gation of disease, since we have  so many  better,
more agreeable, and  more certain  tests for the
presence of sugar in the urine, and acid or alkali in
the  perspiration, than  our forefathers had,  when
they were obliged to test for those substances with
their gustatory nerves.   With the eye we  must
study the physiognomy,  the color and fulness or
opposite of the  skin, the  presence or absence of
eruptions, and their many  various shades  of  differ-
ence or likeness, the general outline of various parts
of the body, to determine whether there be fracture 
                       25
of bones, dislocation of articulations, the presence of
tumors, and their specific characters. With the same
sense we must study the various secretions and  ex-
cretions  of the  body,  and  the  discharges from
diseased parts.
  With the touch  we measure the consistency of
parts, as their  hardness or softness, their degree of
sensibility  as determined by  pressure; by this  we
judge of the presence or absence of fluid in tumors,
of pus within inflamed parts, of serum or other effu-
sions into cavities, of the condition of the uterus in
the pregnant and non-pregnant woman; by the touch
we  ascertain the presence or absence  of crepitus in
supposed fractures, of grating in diseases of  the
joints, of tactile fremitus  in external or internal
aneurism, in valvular diseases of the heart, in inflam-
mation  of pericardial or pleural surfaces ;  by this
we  determine the  force of the vocal fremitus in
various altered conditions of the lung or pleura; by
the touch we judge of the temperature of the body,
a symptom which,  within a few years, owing to the
more accurate  information  afforded by the ther-
mometer, has assumed a certainty and importance it
has never before had.
  With the ear we must examine the natural and
morbid sounds which the organs give rise to by their
motions, including amongst these  the various and
                        3 
                       26
important signs afforded by  the respiratory  and
cardiac movements, whether in health or disease.
With this sense we are to determine the signs af-
forded by percussion, the crepitus of fracture, or of
diseased  and grating joints, and of  subcutaneous
emphysema.
  By this, also, the many and important changes of
the voice are to be appreciated, such, for instance, as
the weak and  whispering,  or almost  extinct voice
of membranous croup, the rough and husky voice of
catarrhal  or ulcerative  laryngitis, the  feeble and
touching  tones  of the dying,  or t^e delicious and
happy notes of the convalescent, the shriek of the
maniac, and the dull and soulless sounds which issue
from the mouth of the half-comatose  or the semi-
idiotic.
   As to the smell and taste enough has been said to
show that they, also, must be used in the observation
of many cases of disease.
   I think I have said enough to  convince you that
to become practical physicians we need  that one of
the presentative faculties, called the External or Per-
 ception, quite as much as in any other of the practical
 arts of life.  And  not only so,  but these senses of
 external perception are capable of cultivation in the
 highest degree, and to attain to great perfection in
 their use in medicine,  they must  be trained and 
                       27
practiced  by constant  use  upon the object they are
to study,—the sick man and his various symptoms.
  Not only, however, must this faculty of external
perception be used  in the observation of cases of
disease, but still higher faculties of knowledge must
be employed in  the  same operation.  Memory, the
conservative  faculty;—the  reproductive faculty,
whether reproduction without the will or suggestion,
or  reproduction with the  will  or reminiscence;
the representative  faculty,  imagination,  to  place
afresh before the consciousness similar or  dissimilar
cases  observed in the past, or culled from the stores
of rother men's experience, for  the purpose of com-
parison with the present; the elaborative faculty,
comparison  or  the  faculty of relation,  including
judgment or reasoning, the highest faculty  of all,
whereby we determine the differences or  likenesses
between things, and  thus enter judgment  upon
the sick  man  before us, and prove  to our self-
consciousness that he is the subject of such a disease
or injury, and of none other, and  that the proper
remedy and treatment is thus and so.
   If,  gentlemen, these various faculties of the human
intelligence are  necessary for the proper observation
of a case of disease, how can any one hope to make
himself a competent physician except by developing
them at the  bedside ?  Where else can he find the 
28
phenomena, by the study and comparison  of which
these faculties are to  be used, trained, practiced, de-
veloped,  strengthened?   Use, alone, in this world
makes perfect.  Repetition,  iteration, and reitera-
tion, are  the only means  by which we can establish
in the nervous centres where the various faculties I
have cited  to you have their location, that curious
and wonderful ease and facility of function or play,
which we call habit, whereby the perceptions derived
from our senses, instead of being  converted  only
slowly and by an intense  action of the will and at-
tention into clear judgments  and  determinations to
action, become  so rapid  and so  apparently inde-
pendent of the will, as to seem automatic or reflex.
The power of habit to render all  and every kind of
human work which  the  vocation of the man may
call upon him to do,  whether mental or bodily work,
coarse or fine, as digging and delving, pin-making,
organ, violin or piano playing, running up long lines
of figures without conscious effort, cutting for cata-
ract or section  of the cornea, iridectomy  or ampu-
tation at  the hip-joint, or passing a ligature around
the carotid or subclavian  amidst nerves on which life
or limb depend, percussing the chest or feeling the
pulse, analyzing the  sounds of a  diseased heart, or
of an aneurismal tumor,  all, all become easier, more
rapid, and more certain and accurate, in proportion 
                       29
as they are more perfected by habit.  Habit makes
biting  the nails  more and more easy,  agreeable,
necessary,  and  automatic or unconscious.  Habit
makes  the inveterate  opium-eater a  slave bound
hand and foot.   Habit makes the drunkard a con-
stantly worse drunkard.   Habit makes the miser's
gold ever more rich and rare to him.  Habit makes
the benevolent  man  to  become at last little  less
than an angel of mercy.   Habit enables  the geolo-
gist and astronomer to read the strata  of the earth,
and the courses of the stars, as a child reads its easy
lessons.  Habit, finally, enables the trained and  ac-
complished physician  to  unravel the most obscure
and dangerous cases of disease, and, greater  than
all, sometimes puts within his control, in the form of
scientific therapeutics, the issues of life and death.
Ah!  gentlemen, study, clinical  and therapeutical
study, long, and  assiduous, and earnest, and these
alone,  make  the  great physician,  and,  moreover,
make his difficult and responsible duties compara-
tively easy and certain.
  It seems to be a law of our nature that, to com-
prehend fully the qualities of any object external to
ourselves, we must  see it, or handle it, or taste it
and hear it—or, in other words, observe and study
it by as many of our senses of external and internal
perception, as we can bring to  bear upon it.  Take 
                       30
any  of  the world-famous productions of  human
science or art, and note how impossible it is to form *
any clear, satisfactory, and definite idea of it in the
mind, from mere descriptions, or even  from  copies.
Take the Apollo Belvidere: who ever found that
any description, or picture, or photograph, or  copy •
in marble or bronze, gave him a true  idea of that
famous statue ?  Not until his own eyes have seen it,
in all its glory, in the Vatican, can he be said to com-
prehend and make  it a part of his own consciousness.
Or, take the greatest picture in the world, the Trans-
figuration of Raphael.  How tame all word-pictures
of that marvellous production.   How short ofx the
truth even the best copies by the ablest hands.   Who
grasps the beauty and  majesty of our Capitol at
Washington, or of St. Peter's at Rome;  the exquisite
grace of  the Cathedral at Cologne, or of the  ruins
of Melrose or Tintern, until the  eye  itself has ad-
mitted to the consciousness of the individual, the
size, form, and outlines, which make up those  won-
derful human works.  So, gentlemen, all philosophy
and  all  experience tell the  same story,  that, "In
the  sweat of  thy  face  shalt  thou  eat  bread."
Whether it be the grace and beauty of the Apollo,
the glory of the Transfiguration, the grandeur of St.
Peter's, the majesty of the Capitol, the soft tender-
ness and antiquity of those old  Scotch  and English 
31
 ruins, or the daily work of the physician  amongst
 wealth and luxury, or rags and wretchedness; educa-
 tion and  refinement, or  ignorance  and brutality;
 amidst cholera or typhus, railroad "accidents or the
 roar of battle;  amidst the big and little things of the
 profession;  restoring the  blind to sight, the lame to
 walk, the dying to life; from  scybala to scirrhoids,
 from expectorations to expectations, from diagnosis
 to prognosis, and from  therapeutics to the final re-
 covery or  death,—all tell the  same story,—nothing
 but work, work, toil, education of the faculties, ex-
 ternal and  internal, of  each  individual man  who
 hopes and desires to become a proficient in his work.
 The sculptor, the painter, the architect, the philoso-
 pher, the poet, the statesman, the savant, the doctor,
 " the butcher,  the baker,  and  candlestick  ma-
 ker," all must toil and educate themselves if they
 hope to become great and skilled in their vocations.
  Gentlemen, to conclude this, I fear, wearisome
 discourse, I  am about to make a somewhat long ex-
 tract from the writings of the great man to whom I
 have already referred,—Sir William Hamilton. And
 what can I do better than to cite to you some of the
 conclusions  on the  manner and effects of study, at
 which  after his long years of devotion to the analysis
of the human mind, this most profound and accom-
plished  thinker arrived.  The opinions of such a 
                       32
student may well be listened to, and most carefully
adopted into our own consciousness for use and pro-
fit, and especially for encouragement.   The extract
which  I am about to make, concerns the  subject of
attention,—that concentration of the mind, by a de-
termined volition, upon any matter which it is desira-
ble for us to thoroughly comprehend and understand.
  Hamilton  says:  "Before leaving this  subject, I
shall make some observations on the value of atten-
tion, considered  in its highest degree as an act of
will, and on the importance of forming betimes the
habit of deliberate concentration.
  " The greater capacity of continuous thinking that
a man possesses, the longer and  more steadily  he
follows out the same  train of thought, the stronger
is his power of attention;  and in proportion to his
power  of attention will be the success with which his
labor is rewarded.  All commencement is difficult;
and this is more  especially true of intellectual effort.
When we turn for the first time  our view on any
given object, a hundred other things still retain pos-
session of our thoughts.   Even when  we are able,
by an  arduous  exertion, to break loose from  the
matters which have previously engrossed us, or which
every  moment force  themselves on our  considera-
tion;  even when a resolute  determination, or  the
attraction  of the new object, has smoothed the way 
33
on which we are to travel; still the mind is con-
tinually perplexed by the glimmer of intrusive and
distracting thoughts, which  prevent it from placing
that which should exclusively occupy its view, in the
full clearness of an undivided  light.   How great
soever may be the interest which we take in the new
object, it will, however, only be  fully established as
a favorite, when it has been fused into an integral
part of the system of our previous knowledge, and
of our established associations of thoughts, feelings,
and desires.  But this can only be accomplished by
time and custom.  Our imagination and our memory,
to which we must resort for materials with which
to illustrate  and enliven our new study, accord us
their  aid unwillingly,—indeed only by compulsion.
But if we are vigorous enough to pursue our course
in spite of obstacles, every step,  as we advance, will
be found easier; the mind  becomes more animated
and energetic; the distractions gradually diminish;
the attention is more exclusively concentrated upon
its object;  the kindred ideas  flow with greater
freedom and  abundance, and afford an  easier  se-
lection of what  is suitable for  illustration.   At
length, our  whole system  of thought harmonizes
with our pursuit.   The  whole man  becomes, as it
may be, philosopher, or historian,  or poet; he lives
only in the trains of thought relating to this charac- 
34
ter.  He now energizes freely, and consequently with
pleasure;  for pleasure is the reflex of unforced and
unimpeded  energy.   All  that  is  produced in this
state of mind bears the stamp of excellence and per-
fection."
  After describing thus  the nature and uses of at-
tention, Hamilton  gives various instances from the
history  of great men, of their  opinions as  to  the
value of this quality of the mind, and of their own
special  habits.   He  states that  Newton replied to
some one who complimented him on  his  genius,
that " if he  had made any discoveries it was owing
more to patient attention than to any other talent."
He quotes Mrs. Siddons as attributing the whole su-
periority of her unrivalled talent to the more intense
study which she bestowed upon  her parts, and says
of Descartes, that like Newton, he arrogated nothing
to the force  of his intellect, but attributed what he
had accomplished more  than  other  men,  to  the
superiority of his  method.  Genius itself,  he says,
has been analyzed  by the  shrewdest observers  into
a  higher  capacity  of  attention.   Genius,  says
Helvetius, is  nothing but  a  continued attention.
Genius, says also Buffbn,  is  only  a  protracted
patience.  And  Cuvier asserts,  that,  in the exact
sciences, at  least, it is  the patience of a  sound 
                       35
intellect, when invincible, which truly constitutes
genius.
  Gentlemen, I do not know that there are any embryo
Harveys, or Sydenhams, or Jenners, now before me,
but I do know that there must be, amongst the
students who have so kindly listened to my words
this  day, some ardent  and intelligent spirits, upon
whom the arguments in favor of a  patient and as-
siduous cultivation of habits of strict medical obser-
vation,  at the clinical lectures to be given  in this
room and elsewhere, cannot  fail to produce some
generous fruit.
  That the discussion of the necessity, and inevitable
benefit to be derived from clinicalstudy, which you
have heard from  me this day, may,  in effect, arouse
in some  of you,  a  determination to severe and sus-
tained study  and attention  to this department of
medicine, is the best wish I can give you. 
 
         ADDRESS

            DELIVERED BEFORE THE


VNAGERS,  MEDICAL  SIMP, AID STUDENTS

                 OF THE

      PENNSYLVANIA HOSPITAL,

                 ON THE

OCCASION OF THE OPENING OF THE NEW  LECTURE
           AND OPERATING ROOM,


        JANUARY 9th, 1869.



   By J.  FORSYTH  MEIGS, M.D.,
        ONE OF THE MEDICAL STAFF OF THE HOSPITAL.



           PHILADELPHIA:
     LINDSAY  & BLAKISTON.
                 1871.
0078
220328 
 
 
 
 
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