-* II TPTf- ~-/*- DR. BRAINARD'S ADDRESS CANDIDATES DEGREES AND LICENSES, MEDICAL INSTITUTION OF YALE COLLEGE, JANUARY 21, 1840. ^ 4j wmmmrr™^ i- lJ"MM|f nr, the Sr* Y) ANNUAL ADDRESS TO THE CANDIDATES DEGREES AND LICENSES, MEDICAL INSTITUTION OF YALE COLLEGE, JANUARY 21, 1840. V BY DYAR T. BRAINAR-D, M. D. MEMBER OP THE BOARD OP EXAMINATION. PUBLISHED AT THE REQUEST OF THE CLASS. ^ I ( '■ ■"Ss \fy'\ O- X^A NEW HAVEN: PRINTED BY B. L. HAMLEN. 1840. ADDRESS. No aphorism is perhaps better established than this, that " art is long and life is short;" and of all arts, that of reliev- ing human suffering and prolonging human life is probably the longest; and any arts or sciences that will effect either or both of these objects, must commend themselves to every man of feeling and judgment. There are many sciences, and some of them immediately auxiliary to the science of medicine, that may be pursued with perfect certainty of correct results. In short, every science can be, where the ground we start from is fully known and all its minutiae are embraced in our view. Hence arises the accuracy of mathematical reasoning—every arc, every line, every angle, is perfectly definite; every increment or decrement is governed by some known and fixed ratio, and all its data are as fully within the grasp of the mathemati- cian's mind as the compasses are in his hand. It is true, with all his means he must exercise intense application ; all his ideas which he may have occasion for must be kept in perfect order, and in this way he arrives from one truth to another to a true conclusion. Medicine, however, is a different science. Here we have not always those accurate definitions which at once embrace the whole object and exclude every other. Even man that we operate upon, and for whose good we pursue our science, we are unable to define to our satisfaction, and his diseases refuse, in many instances, to be bounded and hedged in by such walls and barriers as nosologists have attempted to es- tablish. The merest tyro can tell you what is a circle, but learned physicians dispute about the definition of a fever. It is our province to examine and investigate the laws of ani- mal life, and still we have difficulty in defining an animal. 4 Nature presents herself to our view, and at first all appears plain and simple ; but a closer inspection at once satisfies us that much is concealed from our sight—bounds are set to our researches, and she says at once, "hitherto shalt thou come but no farther." All physicians regret that their art is rather a conjectural than a perfect one, and that a disease is some- thing to be cured by probable means, rather than to be sub- dued with certainty by the efforts of reason. We should however always depend on our inductions, whether they relate to disease or any thing else, when the grounds we start from are fully known and perfectly understood; but in nu- merous diseases there will be many inaccessible points, about which we are undecided, and here conjecture must occupy the place of argument, and probability that of fact. Here the object of the physician should be to discover as much truth in relation to the case as possible ; and for this purpose he should not reason like one who has an opponent, and endeavor to gain a victory at the expense of truth ; nei- ther should he reason like one who has none, endeavoring to make that very plausible to himself which is not so satisfac- tory to others; but he should impartially exercise his whole mind, give every fact its due consideration, examine thor- oughly the grounds of his conclusions, and be satisfied as far as possible. In some respects his task is like the mathe- matician's, and were his starting points always as well estab- lished, his results would be equally conclusive. Some phy- sicians have written on metaphysics, and more have resorted to that science in their ordinary communications and inter- course with each other; but I would say with deference, for my means of knowledge on that point have been limited, that very few have distinguished themselves in that depart- ment. Our field is in the natural sciences ; and if we seek for distinguished authors in any of them we shall find them among our medical brethren. We have nothing to do with metaphysical subtleties. Obscurities thrown over some points, and all the light of our minds drawn to a focus on others, will not aid us, when facts rather than arguments stand in 5 our way. If a man argues for victory, (and this is almost invariably the case when two argue together,) the whole ar- mament of logic is called in requisition; syllogism meets syllogism—the horns of one dilemma are locked in those of another, and arguments on the shoulders of demonstration meet each other with all the impetus and momentum of ap- proaching locomotives. Of disputations of this kind, I must confess that physicians have had their share ; and I think I may say, that from the time of Hippocrates to the present, the disciples of different schools, and the advocates of differ- ent theories have been constantly coming into collision. I would not here, even were it in my power, attempt to enu- merate the different medical theories which from time to time have been offered to the world, or even state the grounds on which some of them have been founded. Many were highly extravagant, and still, there are but few from which important materials for a correct system of physic have not been derived. I need but refer you to the Galenists and the Chemists, the Dogmatists and the Empirics, the humoral pathologists and their adversaries, and then to call to your minds our present theory of physic. In seeking for vegeta- ble remedies, Medea, in her dragon car, did not visit places more remote, mountains more rough, and plains more vast and solitary, than are many of those regions which furnish a large portion of our vegetable remedies; and Paracelsus himself would feel as though he had been for a long time a truant from his own school, were he to see but half of the chemical medicines in our present Pharmacopoeia. The truth is, in our days chemistry and botany have united to- gether, and giants are their progeny. At this age of the world, if we are satisfied from frequent observation, that any given remedy will with certainty relieve a particular symp- tom, or cure a particular disorder, we do not enter into all the whys and wherefores of its modus operandi, we do not first endeavor to bend it to some cherished theory of our own; we may and should inquire whether particular symptoms should be arrested, and whether worse ones will not follow. 6 In short, we should know exactly what we want to do, and if this remedy will do it we use it at once. We rejoice that there are some specifics, and we wish there were more ; but it unfortunately happens, that for the majority of diseases there are none ; here we resort to all the remote and proxi- mate causes ; here anatomy and physiology direct us to all the organs and their functions to see the nature and charac- ter of the difficulty—where the seat of the trouble is, and where the danger is the greatest, and there we apply our force. To the humoral pathologists we are also indebted for a portion of our present medical notions. It is true we do not adopt any of their extravagant ideas ; we do not speak of the fluids as being either acid or alkaline ; we do not wait in a violent fever for fermentation and concoction, and then proceed to discharge the peccant matter; but I believe most physicians, under one pretense or another, do and will have regard to the state of the fluids. The late Dr. Hosack, in the treatment of fever, lays it down as one of the most impor- tant indications, to obviate any tendency to putrefaction in the fluids. From those who adopted the expectant system, and maintained that nature effected the cure—who advoca- ted the doctrine of an efficient vis medicatrix naturae, we have derived some useful information. This is probably more manifest in our present treatment of wounds, where we discard all stimulating balsams and salves, and do noth- ing but remove all impediments and keep the parts in conti- guity. And here I would remark, that it is astonishing the medical faculty should have been so long in establishing the present method of treating wounds. Ambrose Pare, the inventor of the ligature, accidentally found out that stimulating balsams, heat hot and poured into gun-shot wounds, might safely be omitted, and that under a more feeble plan of medication, the wounded would be ea- sier and recover sooner. About his time, too, a very valua- ble sympathetic salve was discovered, which was applied, not to the wound, but to the instrument which made it, and if you only cleansed the wound, stopped the hemorrhage, 7 and kept the sides in contact, it worked wonders, in incised wounds, especially if you did not from day to day examine with a probe to see how it progressed. But this plan was too superstitious, and was accordingly rejected by the learned until the time of John Bell, who adopted all of it except the salve, which he probably had forgotten. But besides wounds, we sometimes see disorders that are best cured by being let alone, or at any rate by giving advice rather than medicine. Cases of dyspepsia are not un frequent, where abstinence from excessive eating and drinking, will effect a cure with more certainty than emetics and cathartics, followed by tonics and stimulants; and in the convalescence from many diseases, we occasionally do harm by attempting to accelerate the salutary operations of nature. There was a time when it was considered philosophical to explain unintelligible things in unintelligible language, but this method of philosophizing was set at naught by Bacon. He drove the learned back to their first principles; he taught philosophical builders to look to their foundations, and in rearing their edifice, to place no stones except on such as were permanent and solid. Boerhaave was a disciple of his school, and he formed his system of physic, from such frag- ments of others, as would answer a builder's use. Much of his material was taken from Hippocrates and Sydenham, and if it be said he too much favored the humoral pathology, he only used it as a cement to consolidate his materials. At that period, the structure was not completed, and to this time it remains unfinished. Dr. Cullen, whose descriptions of diseases will forever remain as a monument to his well earned fame, it is true, added but little to the theory of physic, but he abstracted much that could be safely omitted. His critical eye detected much which was defective, and much which from its weight produced weakness rather than strength. He seized the Materia Medica and wrung it like a sponge—he entered the hall of the apothecary and swept it as with a besom. Every thing which former experience had established he left—every thing useless or doubtful was 8 thrown among the rubbish. Can it be wondered at, that some things valuable and precious were also thrown out ? These things we are now seeking and daily find. When Cullen was in his zenith, Brown appeared in the firmament, and disregarding all orbits but his own, he shone for a time like a splendid meteor, and when he set, he left behind him a train of light, which still continues to illuminate the med- ical horizon. His theory is remarkably well calculated to satisfy those who study physic only as a science, but unfortunately, it does not afford so much aid to those who practice it as it promises. Its influence however is great, and it has pro- duced important changes in the treatment of many diseases. The lancet and other depleting and evacuating remedies, are not now used to that extent as formerly, and we now be- lieve there are some diseases which do not require a very decided antiphlogistic course. There have been a number, who since the time of Brown have attempted to modify, im- prove or entirely change previously established medical prin- ciples, and I believe we may ultimately derive some good effects from their labors;—time, however, must determine. The profession, ever anxious to benefit their fellow men, will avail themselves of all facts, which may be the results of the experiments of the bold and adventurous, and of all sound reasoning which the zealous and sanguine may em- ploy in support of their views. I have thus endeavored to give you a faint outline of the present state of medicine, and the proper theory, if such it may be called, (selected as it is from portions and fragments of others,) which I think may be safely pursued. It makes no pretensions, it claims no infallibility. If some of its parts are defective, its conservative plan will produce a remedy ; and if there is any where a deficiency, its tendency is to sup- ply itself, even from its enemies. There is, I agree, an eclec- tic character about it, and there are many who would not be so catholic or tolerant in their views. It is however the plan which on reflection I choose, and I must believe that 9 all those who would adopt the shortest, the easiest, and the most certain means of accomplishing their ends, will agree with me. The profession, gentlemen, which you have chosen, is one of very great responsibility, and it imposes on you great anxiety and great labor, both mental and bodily. Hence- forward, if you continue in it, most of your time must be de- voted to study and contemplation. With distressing scenes you will have to become familiar—disease will baffle your best laid plans of action, and pestilence which walketh in darkness will set you at defiance. You are doomed to see pain and anguish, misery and death, without the power of affording relief. There is, however, another and more pleas- ant view of the picture, which will reconcile you to all you may have to encounter. The resources of medicine are great, and you will have the pleasure of seeing numerous diseases submit to your skill. You will enter dwellings where you will see pain and distress, fear and apprehension, and will convert all into ease and happiness,—tears into smiles, fear into hope, pain and agony into health and strength. These are the rich rewards for your hard toils and troubles, and they can be gathered in as great abund- ance from the humblest cot, as from the most splendid man- sion. The consciousness of having relieved pain and distress, of having averted imminent danger, and of having cured threatening and violent disease, by prudent and judicious means, is a compensation greater than the opulent can be- stow. For this reward, how many do you see, the most eminent in our profession, laboring with the most persevering zeal and the most untiring industry. Their labors, it is true, are for the most part required by the wealthy, but let them get once engaged, and wealth and poverty are immediately forgotten—gold in all its forms loses its power. It can neither advance nor retard them in their pursuit. In this enterprise the young physician can always engage to advantage. In all large towns the poor are his first patients; but let not the proud and haughty sneer. His diligence and attention 2 10 are more than an equivalent for the extra skill and limited attendance, which his more experienced brother could bestow, and his labor will surely meet with its reward. Minor troubles you are destined to encounter, and smaller compensation you are destined to receive. You will some- times be censured when you do right and applauded when you are entitled to no praise. You will find the majority of mankind not always the best judges of medical ability, and hence it is, that so many pretenders gain reputation and wealth by their cunning and address. This cannot be easily avoided or very cheerfully submitted to j but the best con- solation for you will be always so to act, as to be fairly enti- tled to your own commendation. But however easy this may seem at first view, it will take much exertion on your part to effect it. And the first requisite I shall mention is indus- try, which will do more for the advancement of any person, than the young and inexperienced will believe. This is a subject, as we all know, which is always held up to them, and for the most part it makes an impression in proportion to their ages, and the older they grow, the firmer will be their belief in it, which is sometimes not fully established, until increased years have rendered its truth of but little conse- quence to them. All I can say is, the sooner a young man believes it the better. The effect of this truth has been so great, that many dis- tinguished for high talents and extensive acquirements, have doubted the advantage of genius. Well they may, if they see it go hand in hand with indolence. But industry to pro- duce its best effect, should be properly directed. The read- ing of one medical book and then another, in the shortest pos- sible space of time, without regard to system or some definite object, is not the best way of gaining the reward of your labors. A better method is, to take up a subject and read the best authors, and compare them. Never be in a hurry, but always be attentive, and always have the object of pursuit in view. 11 In attendance on your patients, endeavor to understand their disorders fully. Make such examinations as will afford desirable information, and such inquiries only as will throw light on the case, and make them in intelligible language and in some kind of order, so that if you are interrupted by a long statement of a case of some one else, (a very frequent sort of episode by the way, and which requires not a little good na- ture and patience to endure,) on its conclusion, you can easily pursue your course. In the examination of patients, much tact and skill are required, and the young physician will often be surprised, to see another of more experience than himself, when called in consultation, learn some very important fact in relation to the case, not so much from his superior knowl- edge, but simply because the elder had made some examina- tion or some inquiry, which the younger had omitted. Every person who practices medicine, should not only have five senses, but should use them. If people who have eyes but see not, and ears but hear not, do not stand high in morals, their chance for distinction in physics will be small. As much can sometimes be learned from the sound of a pa- tient's voice, as from the words he utters, and the eye can discover colors, shapes, sizes and positions, which we have no proper language to describe; but it is unnecessary for me to enumerate the various powers and capabilities of the senses. Another means of directing your labor to advantage, is to keep a journal of all important cases, in which all the symp- toms, prescriptions and medicines with their operations, whether salutary or otherwise, should be recorded. This you can easily do at the commencement of your practice, and it will give you more precision in examining and more accuracy in prescribing. You will also derive great benefit from it, by comparing the cases recorded, with such as may arise. Besides, it is the best method of learning, what the ancient physicians considered of so much importance, the Lsedentia and Juvantia. Never give a new or original pre- scription without taking a copy. If it succeeds, it will be 12 wanted again ; if it does not, you should know it. It is of some value to know the inefficiency of some things; it is of more to know when they produce injury. To err is hu- man, but he who learns nothing from his own errors, will never make a physician. This plan is also the best, to gain that very desirable qual- ification, experience, or the knowledge of truth from personal observation. It is generally thought that those whose prac- tice has been the most extensive are experienced in propor- tion ; other things being equal, it is true. But it is also true, that one man may gain more experience in fifty cases, than another will in a hundred, if the first resorts to all practica- ble means of understanding and remembering them and the other does not. Another advantage resulting from this practice, is, that it enables you to detect the errors which authors and others oc- casionally commit. Do not, however, be too certain that your own observation is always correct, when you are disap- pointed in the effect of an agent recommended by another, for it may be that he used it under circumstances which his eye could detect as most favorable to its beneficial influence. I believe most physicians who have been long in practice, have their favorite medicines, which they will use to better advantage than they can others equally good, and simply be- cause they are more accustomed to them. But there are some medical men who have written on dis- orders they never saw, and who have advised remedies, of whose action in such cases they were ignorant. This plan, I think, will enable you better to distinguish between medi- cal scholars and medical practitioners; the former of whom write too many books, and the latter too few. Most of our standard authors, however, can be relied on ; and if all, like Sydenham, Cullen, and Heberden, had only written from their own personal knowledge and observation, the profes- sion would have been much benefited. While I thus allude to the errors which some medical wri- ters have committed, allow me to put you on your guard 13 against like faults. Men of ardent minds—of deep study, and extensive knowledge—men who would shrink from any deliberate mis-statements, have been so bound up in their profession ; so anxious to establish their views and theories, because they fully believed them ; so desirous to gain a high standing, as public benefactors, that their eyes have become dazzled by their anticipated splendor. They have seen either falsely, or through deceptive media, and have reported accordingly. Some practicing physicians we occasionally see, who, from the same ardent temperament, are inclined to exagger- ate. Listen to them, and you hear tales of terror. Their language puts all diseases they encounter, in their worst forms, and all accidents they are called to, are of the most penetrating, compound, lacerated, and contused description. Their sanguine temperament gives to their narrations a san- guineous character. Though their patients often recover, still this disposition to see things in their worst, and most dan- gerous forms, will many times do injury. Such physicians, besides talking to their patients of slight symptoms, as being the harbingers of greater ; of suggesting to them difficulties which may arise, and of directing their minds to particular organs, which, if deranged, portend the greatest danger, are induced to resort, without sufficient cause, to the most ener- getic and decisive medication. It is not too much to say, that such management would be more apt to make a well person sick, than a sick person well. Your course should be different; you should seek after truth, and on all proper occasions communicate it. If you have any disposition to exaggeration, look to it, and be on your guard against it. In visiting the sick, give them all the en- couragement which the facts will warrant, showing them or their friends, where there is hope, and explaining to them, as far as you can, whatever is obscure. Avoid all mystery, and all affectation of gloomy solemnity. Let your manner be cheerful, composed, and candid. This alone will relieve much distress. How many are the cases of accidents, to which a physician is called, where the whole house presents 14 a scene of confusion and fear! and how often is it in his power to establish order, and allay all their apprehensions at once, by calmly examining into the extent of the mischief, and showing how easily it may be remedied ; and doing it too in such a way, that the very sound of his voice, and ex- pression of his countenance, will be received as good indor- sers for the correctness of his opinions! As you are now about to establish yourselves in your pro- fession, the relation in which you will stand to various mem- bers of the community, will be a peculiar one. Numerous good services are constantly interchanged by all; but as physicians, your duties and services will be rendered when they are most wanted, and, of course, when they are most felt. From time to time, one individual of a family, and then another, will be sick, and require your attendance. In the natural course of things, and by judicious manage- ment, they will recover, or, if occasionally one dies, and you have been faithful and attentive, and have done all in your power to afford relief, you will have father, mother, and chil- dren, all looking to you for protection in sickness, and im- plicitly obeying your directions. This confidence will be ex- tended to other things, and you will be their adviser in other matters, and will often become acquainted with their pro- jects and misfortunes, their failings and their faults. But it is when people are reduced by sickness, and irrita- ted and almost exhausted by pain, weakened in mind as well as body, that you will most observe them to say and do a thousand things, of but little consequence in themselves, which should not be repeated. It is here, too, where the physician sees and learns many trifling incidents, which, if generally known, might mortify the inmates of the family. He should, therefore, be a man of the strictest honor and prudence, and if affectation be ever admissible, he should pretend not to observe trifles, which, if it was thought he perceived, might wound the feelings of others. His position gives him great opportunities, either accidentally or confiden- tially, of observing and learning much, which, under all or- dinary circumstances, he should keep to himself. He should 15 take no advantage of his peculiar situation—he should do no act but what was consistent with honor and honesty, and never charge extravagant fees, because he had a patient who dreaded his tongue. Other things I might say, if time would allow. I might speak of benevolence and firmness, and I might present to you all the virtues for your acceptance, and all the vices for your rejection. It is customary, on occasions like this, to in- troduce and enlarge upon all the rules of policy, and to point out all the avenues to full practice and eminence; but this has been done again and again, by those who have already reached the goal. It is also customary, gentlemen, on such occasions as this, to mention morality among the qualifica- tions necessary to secure to you competence and respectabil- ity in your profession. It is customary to paint her in all her beauties, to adorn her with all her emblems of power, and to display her with all her implements of utility. It is custom- ary to show that her name is wisdom, and that all her ways are ways of pleasantness, and all her paths are peace. In as- semblies, whether composed of the young or old, of scholars or citizens, among all classes and all denominations, morality is held up as the greatest temporal good. A high standard of morality is insisted on, as being abso- lutely essential to the proper exercise of the most extensive acquirements, and the greatest and best of the mental facul- ties. Without it, knowledge and learning and art, quick perception, brilliant genius and sound judgment, would be curses to their possessors, and to all within their influence. The least departure from it, is marked with danger; one immoral act leads to another, and what at first might be re- garded as trivial, in the end acquires a force almost irresisti- ble. But on this subject and in this place, I should not dwell, for here you have men whose duty and pleasure it is, and whose ability is equal to the task of making such deep and lasting impressions as will not be obliterated. With the hands of skillful and practiced masters they delineate morality in all her forms, with all her grace and all her purity; they contrast her with vice and hold up to view the startling pic- 16 ture. It is from the labors of such men, that so much good has resulted to the community, and it is from attending to their kind admonitions and practicing their precepts, that the inhabitants of this city derive much of their prosperity. It is a high standard of morality, which constitutes much of the capital of its citizens. It is this, so ably taught and so generally practiced, which fills yonder walls, and attracts from all points the youth of our country. Without it, they would crumble and decay. Science and literature would turn to marble our Alma Mater, and she would stand like another Niobe, cold and inanimate, showing to a proud world what she once had been, and what she then was. Other towns and cities may boast of their distinguished individuals, but this city has been, and now is, ornamented with men preeminent for their learning and talents, their sound morality and their pure religion, which the truly great and good are proud to imitate. Here may statesmen, law- yers and divines, physicians and philosophers, mechanists and mathematicians, look for those who have added lustre to their professions. Need I mention a Sherman or a Whitney; need I call to your minds the great luminaries of Yale ; need I remind you of those eminent physicians and surgeons, now departed, who have held professorships in this branch of the institution, or need I refer you to those philosophers and scholars who have scattered knowledge and science from the other ; or shall I mention its late venerated head, whose eloquence reechoes from the shores of Europe, whose wis- dom and learning were the admiration of millions, and whose piety pointed the path to heaven, and led the way. But why should I attempt his eulogy? Thousands there are, who once filled yonder halls, who sound his praises. Hundreds there are who shall write, in indelible characters, the name of Dwight on the lasting monuments of their country's fame. But, gentlemen, although these have passed and gone, they have gone like the prophet, and each has cast his man- tle behind him, which has fallen on the worthy who have arisen to supply their places, and you still have for your in- structors, the learned, the great, and the good. \