yui^i (a -W/ V ^h&:<^ DR. WILLIAMS'S ADDRESS BEFORE THE SUFFOLK DISTRICT MEDICAL SOCIETY, APRIL 30, 1853. ADDRESS DELIVERED BEFORE THE SUFFOLK DISTRICT MEDICAL SOCIETY, AT IT3 ,tatjj tauraaq 3fcting, BOSTON, APRIL 30, 185 3. BY HENRY W. WILLIAMS, M.D., M.M.S.S. PRINTED BY REQUEST OF THE SOCIETY. sr _______ < ------------- BOSTON: DAVID CLAPP, PRINTER.....184 WASHINGTON STREET. MEDICAL JOURNAL OFFICE. 1853. ADDRESS. Mr. President, And Gentlemen of the Suffolk District Medical Society: As I glance over the ranks of this Association* and observe the array of those who have long en- joyed an honorable distinction, for their skill in the practice of our profession, the efforts they have made for its improvement, and the laurels they have gained for their attainments in the sciences to which they have so worthily devoted their moments of leisure; as I see, on the other hand, so many, whose " lack of years" has been " no impediment to let them lack a reverend estimation; " — it seems pre- sumptuous that I should be a speaker, instead of a listener, on the occasion of this annual re-union. But, since this Society has for one of its objects the mutual improvement of its members — since, therefore, nothing which has relation to the two-fold 4 office of the physician, as the restorer and as the guardian of the public health, can be without inte- rest to us — I venture, in accepting the trust with which your Committee has honored me, to ask at- tention to a few practical suggestions respecting a class of maladies, which, though rarely endanger- ing human life, often cast a blight over human happiness. Each year new obligations are imposed on the practitioner of medicine, — new studies demand his attention, — with the constant progress of the sci- ence. And in the ardor with which he pursues the fascinating researches of physiology, or the care he bestows in perfecting the accuracy of his diagnosis by those means of physical exploration with the knowledge of which the present century has seen our profession endowed, there is danger of his for- getting the diseases of minute but most important organs by whose aid he is enabled to prosecute the researches in which he finds so much pleasure. It will be my endeavor to show that the diseases of the eye have strong claims to the attention of every physician: and that, notwithstanding the for- midable catalogue of its affections, their study is one of only apparent, not of real difficulty. 5 In proportion to the rapid advance which the last half century has witnessed in the knowledge of Ophthalmology, it would seem to have received less attention from the great body of the Profession. While we are able to determine the nature of dis- eases of internal organs with an accuracy which shames the oracular ambiguity of pretended, as it would the untaught perception of real clairvoyance: while we can ascertain, in many cases with absolute certainty, not only that a lung is diseased, but the position and extent of the morbid alteration, and even the tissue in which it has its seat:—we have contented ourselves with a less perfect diagnosis of affections of an organ whose position is favorable to the closest scrutiny. As we increase our skill in detecting other pathological changes, we surely should not rest satisfied while the inflammations of one tissue of the eye cannot be distinguished from those of another. Probably there was never a time when an ac- quaintance with these affections was of more impor- tance to the general practitioner. Circumstances must often bring them under his care, even should he wish to avoid them; and they pursue so obvious a course, that the success or failure of treatment 6 becomes evident to all. For the sake of his pro- fession, as well as of his patients, it is important that he should neither manifest nor feel any incom- petence in regard to their management. In these days, when the conceit of ignorance asserts its opin- ions with an assurance which contemns authority and is proof against conviction; — when those, who urge the necessity for intelligence and education as qualifications for another profession, too often en- courage the uninstructed pretender in his assump- tion of functions not less sacred than their own; — when the diffusion of useful knowledge has been even surpassed by its dilution, and infant minds divide their attention between viscera and verbs ; — it is of the highest consequence that the physician should be no less accomplished in practical know- ledge of every department of his Art, than familiar With the principles of his Science. There are no diseases in regard to which popular errors are more common or more mischievous than those of the organ of vision. On the other hand, there are none which offer a better opportunity (in a double sense) for ocular demonstration of the benefits of skilful treatment. The public will not understand that it is unsafe to gratify their penchant 7 for recommending indiscriminate applications, in the disorders of so delicate an organ. With them, an eye-water which cured some one's eye must infalli- bly relieve those of every body else. One gossip would apply a cataplasm; another considers breast- milk a specific ; a third extols the renal secretion as a collyrium of transcendant value. Under these circumstances it is the duty of the physician to acquire such a knowledge, of at least the ordinary affections of the eye, as will enable him to speak with authority and with self-respect, in warning of the danger of popular remedies; and to act with confidence and success, in arresting the rapid progress of destructive inflammation. The increasing frequency of ophthalmic diseases adds to the obligation to become familiar with them. As population augments, there is an increased proportion of the maladies which depend on want of cleanliness, on contagion, and on the strumous (diathesis produced by unhealthy habitations and improper or insufficient food. There are also more of those other diseases of poverty, caused by ex- cessive use of the organ or by the effort of those who are naturally long-sighted to subsist by occu- pations which require continued attention to minute 8 objects. On the other hand, the artificial habits of the rich, the vigils of the student, and the chlorosis of boarding schools are attended or followed by their own peculiar morbid conditions of the visual organ. In regard to nearly all these affections very much depends upon hygienic treatment; and this can only be directed by the ordinary medical attendant. Un- less he enjoins watchfulness, the purulent discharge from one eye may be conveyed to those of a whole family or an entire neighborhood. If he do not advise prudent exercise of the visual function, the student or the artizan may find himself deprived of that sense which has for him the highest value, on which, more than all others, depends the realization of his hopes. Another important inducement to the study of the affections of the eye, may be found in the aid they afford in illustrating the course of disease in other parts of the system. The physician has here an opportunity which he nowhere else enjoys, for familiarizing himself, by actual observation, with pathological phenomena, and noting the manner in which they are modified by remedies. The advan- tage he may derive from having the minutiae of morbid processes thus open to his inspection, should be esteemed too precious to be disregarded. 9 It is natural that, sooner or later, almost every physician should acquire a reputation for his know- ledge or management of some particular diseases. But he should remember that the human body is not a machine, the different parts of which may be separately repaired without taking into considera- tion the reciprocal action they exert upon one another. As he will fail to be successful in the treatment of any special class of affections if he neglects to perfect his knowledge of all the general principles of his profession, — so, on the other hand, he should eagerly avail himself of the advantages afforded by any one disease for studying the analo- gies of symptoms and the modifications caused by peculiarities of constitution. It is needless to say more in regard to the impor- tance and value of an accurate knowledge of the maladies in question. My principal object in this address remains to be accomplished ; — to point out the best means, and the little difficulty, of acquiring this information. The constant enlargement of the range of medical studies has not been without its attendant evils. It has, as it were, compelled us to rely too much upon books. Valuable as are these records of past 2 10 experience, they must be but imperfect substitutes for personal observation. To use the words of a judicious French author,* " The improvement of the mind in regard to the extent of its acquirements is often counterbalanced by the loss it sustains in respect to the force and permanence of its concep- tions ; and we often neglect objects which may be seen and examined, in order to inquire what others have imagined and said." The Arabian physicians justly regarded a large infirmary as a gallery in which the student would find a display of instructive pictures. As these can be but imperfectly described in books, — so a disease to be fully appreciated must be seen. Others besides Hippocrates enjoyed the privilege of examining the records of cases, preserv- ed in the temples of Esculapius; but he went beyond this, and it was the extent to which he exercised his own talent for clinical observation, which made him the founder of a science. Little did he imagine that practical medicine could ever be taught from a professorial chair, at a distance from the objects of its application. We cannot hope, then, to attain practical knowledge of the * Cabanis. " Sur la Revolution et la Reforme de la Medecine. Paris: 1804." 11 minute diseases affecting so delicate an organ as that of vision, otherwise than by the careful and frequent study of these living pictures. From this study many have been deterred by the formidable catalogue of ophthalmic diseases. While the recognized affections were few in number ; while even the nature of so important changes as those which constitute cataract was a disputed point; it was an easy task to acquire the know- ledge included within bounds so narrow: but, as the list of appreciable morbid conditions swelled to hundreds, many abandoned the attempt to make discriminations which were no less nice than important It has therefore become requisite to inquire if we may simplify the methods of arrangement and in- struction, to meet the necessities imposed by the multiplication of the facts which demand attention. I believe it is in our power to do so, to a very con- siderable extent, by endeavoring, in the study of the various affections, to apply the same principles which guide us in regard to those of other organs; by learning to define the precise situation of the malady, and to recognize the features which dis- tinguish it from affections seated in different, though contiguous, portions of the globe. 12 As the eye is a composite organ, made up of tis- sues of entirely different nature, the affections of its various parts must oftentimes be equally distinct, — and analogous to those of similar tissues in other portions of the system. It should be our aim, in the first place, to learn to analyse the symptoms and determine the primary seat of the disease. We are not satisfied, when symptoms of thoracic disease exhibit themselves, unless we can determine whether it implicates the serous covering of the lungs or the mucous membrane lining the tubes which ramify through their substance: — why should we be content with generalization in the pathology of the eye] Though a classification according to anatomical divisions may not open a royal road through the seeming labyrinth of ophthalmic disease, it may serve as a clue to guide us through its mazes. Such an arrangement is not merely useful in facilitating diagnosis, it often serves at the same time to indi- cate the treatment. Whatever other tissues are secondarily involved, the fons et origo mali should be sought as the point towards which our efforts should be primarily directed. As it would be useless to re- sort to constitutional treatment for an external 13 affection which may be controlled by merely local remedies; — so it would be idle to rely on these, for subduing inflammation of an internal tissue which they cannot reach. Almost all the ordinary diseases of the eye may be included in a very few classes: those of the con- junctiva, the cornea, the iris, and the retina, comprise nearly all which the physician has usually occasion to treat. The sclerotica, though sometimes seconda- rily affected by contiguity with other membranes, seems to have but one inflammation peculiar to itself, — that which is known by the name of rheu- matic ophthalmia. The various forms and degrees of opacity of the crystalline lens require most care- ful study as regards the question of operation, but they possess less interest for the physician, in any other point of view, since they are essentially chro- nic in their nature and are not to be removed by other than surgical means. Yet they should receive sufficient attention to enable the practitioner to form the diagnosis between these and other causes of di- minished vision; so that errors similar to those I have recently had occasion to notice may not recur. In one instance a patient was pronounced to have cataract in both eyes, when the actual disease was a 14 clouded condition of the cornea, easily removed by a patient use of remedies; and in another case an individual was sent several hundred miles, by her physicians, for the purpose of procuring suitable spectacles in Boston. She returned to Xew Bruns- wick with well adapted glasses ; — but only after cataracts had been removed from the field of the pupils. If the physician can distinguish the ordinary forms of diseases of the four tissues I have mention- ed, he will be able to determine, with little diffi- culty, the character of the rarer affections. It is related, that a young man, after hearing a decision pronounced in court, in a cause where the merits of the case were perfectly apparent, remarked to the judge, that his position on the bench was a most easy one, since he had only to decide between black and white. " Yes," was the reply; " but what would you do in cases of a grey color I " By careful train- ing in the discrimination of strongly contrasted cases, the physician obtains the requisite skill for passing judgment on those which are in less bold relief. As a general rule, the diseases included in each of these anatomical genera have peculiar features, 15 sufficiently well marked to distinguish them from all the others. Thus the affections of the conjunc- tiva differ from all inflammations of the other tis- sues, in two important particulars: in the description of pain, and the form of vascularity which attends them. The patient complains of itching and smart- ing, and, though the pain is sometimes acute, it has nothing of the sensation of tension or aching which accompanies deeper seated inflammation. Its irre- gular net work of scarlet-tin ted vessels is evidently superficial, and may be moved over the surface of the sclerotica. In inflammation of the fibrous tunic the pain and the injection are entirely different. The tension and aching felt are not confined to the eyeball alone, but extend to the supra-orbital and temporal regions: the injection is deeper seated, and, instead of an inosculating net work, we have a circlet of straight filiform vessels, of a pink or purplish color arranged like rays around the cornea. When either of the internal structures, the iris, the retina or the choroid, become affected, similar pain is experienced but we have, superadded, changes in the appearance of the iris, or a diminution of the visual power to a degree far greater than the mere obvious symptoms seem sufficient to explain. 1G But it is perhaps supposed that a few large classes may include many species and individuals. Such is indeed the fact, if we endeavor to draw well defined lines between all the varieties of the affections of the different structures. But to the general practi- tioner these minute distinctions are not essential to success. The situation and general nature of the malady being understood, his own judgment will not mislead him in proportioning the activity of the treatment to the severity of the symptoms and to the state of the constitution. All the ordinary affections of the external tunic, covering the anterior portion of the globe and inner surface of the lids (which comprise by far the larger portion of the cases which present them- selves), may be included in three varieties. All of these offer the phenomena I have mentioned as proper to conjunctivitis, but differ from each other in presenting minor characteristics. The first, is the simple injection of the membrane, from the irritation caused by the presence of a foreign body. The second is an eruptive disease, offering one or more fasciculi of vessels terminated by a pa- pular elevation, while most of the membrane remains free from injection and in nearly its normal condi- 17 tion. Both these are of slight importance, and yield to the mildest applications. The third, is a malady of far more formidable nature. Under the names and forms of purulent ophthalmia, Egyptian oph- thalmia, ophthalmia neonatorum, gonorrhceal oph- thalmia, its ravages have been a scourge to the human race. Armies, fleets, garrisons, hospitals, schools, have been scenes of its destructive effects. Even its mildest manifestation, the ordinary catarrhal ophthalmia, has done infinite mischief. But we shall find the study of the affections described un- der these various names offering a new facility, if we remember that they are but phases of a single disease, — a muco-purulent inflammation of the con- junctiva. The severity of its symptoms, the viru- lence of its contagion, the rapidity of its course, are modified by circumstances; — but the essential na- ture of the malady is the same. A knowledge of these facts must at once suggest to us the appropriate treatment. We have before us a disease confined to a mucous surface of very limited extent; implicating, in the slightest degree only, the general system. It is evident that our therapeutics must consist principally of those means which are adapted to remove this morbid condition 3 18 of the external membrane; and that, though gene- ral treatment may often be necessary to assist the action of local remedies, it is upon these we can rely with most certainty and safety. The diseases of the cornea may be divided into two classes ; those which ab initio occupy this structure, — and those which are secondarily de- veloped in consequence of previous conjunctival inflammation. The first of these divisions includes the ulcera- tions and opacities which affect children, and young adults of strumous diathesis or disordered menstrua- tion. These essentially differ from the diseases of the conjunctiva, in requiring general treatment to improve the tone of the constitution. Without this, local applications will be of little avail; — with it, the disease, which before had seemed intermina- ble, disappears. It is in affections of this character that a remark made by Sir Gilbert Blane* finds ample confirmation : " Nature may be as much thwarted by the injudicious regulation of diet and exercise as by a perverted use of remedies." The other class of corneal affections comprises the * Elements of Medical Logic, London, 1819, p. 119. 19 vascular and opaque condition resulting from the long-continued friction of the lids, of which the inner surface has become thickened and granular; or from inversion of the eye-lashes. If these irri- tating causes continue to act, the temporary cloudi- ness is replaced by indelible opacity. While their action is incessant, we are baffled in every attempt to get rid of their effects; — by excision of the ab- normal vessels extending upon the transparent cor- nea, by counter-irritation, or by any of those means of which the chronic nature of the disease invites a trial. But, having improved the condition of the conjunctival lining of the lids, or removed the in- verted cilia, we are able to perceive the other morbid changes yielding slowly but steadily to appropriate local treatment. All the affections of the cornea are worthy of our earnest attention. They are interesting as offering fine examples of the phenomena of inflammation in a tissue of low organization. They are modified, more than most local diseases, by the condition of the general health of the patient. Again, our hu- manity is appealed to, to avert the hopeless blind- ness, of which alterations occurring in this structure are the frequent cause. We have the authority of 20 Mr. Bowman* confirmed by our own experience, for stating, that nearly all the inmates of our blind asylums are victims " of inflammations of the front of the eye, its transparent inlet having been de- stroyed or darkened by the ravages of disease which we are quite sure might, in a great majority of in- stances, have been controlled by skilful and timely treatment." They have been sacrificed, in very many cases, to popular errors; — sometimes, we may fear, to the hesitating inactivity or the unskilful inter- vention of the physician. If we turn to the iris, we find a similar paucity in the number of its maladies, and a yet greater uniformity in the treatment on which we must rely for controlling them. Whatever the cause of iritis, its general phenomena offer but slight differences; and the dangers to be averted arise from the same cause, the tendency to obliteration of the pupil. The existence of a syphilitic taint or rheumatic dia- thesis may add to the violence or prolong the dura- tion of the disease, and should have an influence in determining the choice of remedies for cases com- plicated by their presence. But the general indica- tions of treatment are the same as in idiopathic * Lectures, Lond. Med. Gazette, Oct., 1847. 21 iritis; to relieve the local congestion, to prevent the effusion of lymph, and to avert the formation of adhesions of the margin of the pupil. We now find a precious resource in that description of alterative constitutional treatment which would have proved but injurious had it been employed in the strumous diseases of the cornea. The effusion of lymph is prevented, or its plasticity is destroyed and its ab- sorption favored, while, by the agency of the inesti- mable Belladonna, additional precautions are taken for the integrity of the pupillary aperture. But happily, inflammations of this tissue are rela- tively rare; for they must be classed among the most grave affections of the organ, from the im- minent danger of serious consequences involved in its peculiarities of structure and situation, unless we are able to bring the disease, at the outset, promptly under the influence of remedies. The choroid and retina are so intimately contigu- ous that inflammation in one of these tissues can scarcely be distinguished, even if it may exist while the other remains exempt. In addition to the se- vere pain, vision is generally very much impaired. Our only hope of preserving it consists in the use of antiphlogistic and alterative remedies. 22 The tissues, at the affections of which wc have glanced, are all subsidiary to the uses of the eye as an organ of special sensation. We have seen that the retina is susceptible of organic alterations, the consequences of inflammation, in common with the other component parts of the globe; but the most important portion of the pathology of the nervous apparatus consists in those functional derangements by which its office in receiving and transmitting im- pressions of external objects is perverted or abolished. These morbid conditions have a peculiar interest, from the fact that judicious advice, given when the first warning intimations are perceived, may often remove the causes whose continued influence would be sure to produce them; — and also because, if al- ready established, they are susceptible to the influ- ence of remedies in proportion to the shortness of the interval which has elapsed since they first mani- fested themselves. It is sad to see an infant of a few days old, whose eyes had scarcely been opened upon the world be- fore its beauties were forever shut out from the only sense which can appreciate beauty; — but we look with yet more of pity upon the gradual extinction of vision in the poor girl, who loses, not only the 23 enjoyments but the very means of existence; — or upon the longing regrets with which the scholar, who has learned the value of his eyes, finds him- self compelled to forego their use. The physician should endeavor to avert these sad consequences, by timely cautions against excessive and improper use of the visual power; and by advising a change of employment if the occupation cannot be pursued without danger. The wonderful power of adapta- tion, by which the eye is enabled to take cognizance of objects so various in size and distance, has its limits. A near-sighted person may endure an amount of continued application to study or minute work which would fatigue and enfeeble the eyes of one who was naturally long-sighted. A convalescent may do irreparable injury to vision by taxing it too heavily while he awaits the slow restoration of his locomotive powers. The nervous functions partake of the same debility which weighs upon his muscu- lar system, and their task should be as light as those of his limbs. We may also render important service, in very numerous cases, by being correctly informed in re- gard to the principles governing the selection of those auxiliaries to vision, to the aid of which nearly 24 all who fulfil the measure of human life, are, at one time or another, indebted. Few benefactors of mankind have conferred so rich a boon as the good monk whose invention opened a new universe to the short-sighted youth, and restored the failing solace of disconsolate age. Spectacles, — vaccination,— anaesthesia;—what triumphant answers to those who decry the advantages of medical and scientific study. We often meet with cases where patients are en- deavoring to postpone the use of glasses, from a generally entertained idea that the sight will be thus preserved; we see other instances where, spec- tacles having been assumed, the individual continues to be ill at ease, and complains of fatigue and pain resulting from their use. The patient may be assured, in the first case, that he will preserve his sight far better by affording it proper assistance, than by strained efforts to overcome the effects of the natural lessening of convexity of the refractive media. In the second instance we shall probably find the complainant suffering the penalty of the use of ill-chosen glasses, purchased perhaps because they magnified objects, or obtained, it may be, from motives of economy, at a toy shop or of an itinerant vender. Though it is not the physician's province 25 to decide which glasses will precisely suit a patient's eye, he may advise him that those which render ob- jects distinct, without enlarging or reducing them, will be best adapted to assist, without fatiguing his vision. If the person be young and near-sighted, his future powers of vision will depend very much on his adviser and himself. If a young girl is counselled by her instructer, as I have recently known, to wear very powerful concaves during her studies, that she might sit more erectly (although the purpose would have been better answered by glasses of far less strength), — the myopia, which might have been recovered from or diminished by proper education of the power of adaptation, be- comes inalterably fixed, and its degree augmented. If, on the contrary, such an individual is advised to use no glasses, or those of very feeble power, for reading and for examining minute objects, and to endeavor constantly to extend the range of vision, by accustoming the eye to observe objects at gradu- ally increased distances, the natural decrease of the infirmity is assisted and hastened. No precautions can avert the changes which nature has established as among the events of age; — the far-seeing old man may not hope to retain the microscopic powers 4 26 which his youthful eye possessed: but a large pro- portion of the cases of near-sightedness are the re- sult of artificial habits; not of inevitable necessity. Many a scholar may include his myopia among the acquirements he reckons as the results of his intel- lectual cultivation. To increase or diminish it will often depend on himself. He may assist or may neutralize the effort of nature to undo the mischief of which he has been the unwitting author. I have endeavored to prove that the important dis- eases of the organ of vision are neither so numerous nor complicated that they may not be understood by every practitioner. Some reasons remain to be urged in behalf of their study. They are a source of the highest pleasure to the physician; -*■ not only in the satisfaction he feels in arriving, by a single glance, often without asking a question, at a positive and accurate diagnosis; — not only in the interest with which he watches their phenomena, and, reflecting on the analogies they offer, gains new wisdom in regard to other maladies hidden from his observation, — but in the success which attends their treatment. It is no slight gra- tification, among the sad instances where the physi- 27 cian feels that his Art is impotent, to meet with numerous cases where he is conscious of its power. He may not, perhaps, feel entitled to appropriate to himself the prerogatives asserted for some of his colleagues by a late enthusiastic and renowned phy- sician ; who says,* in speaking of the course of an epidemic, " the destroying angel suddenly threw away his commission, and retired from an unequal contest with those highly favored members of our profession:" — but he may assert, without presump- tion, the efficiency of medical skill in a large pro- portion of those diseases of the eye which will require his ministration. Even what was once a miracle is within the power of the ophthalmic sur- geon ; — for lo ! the eyes of him that was born blind are opened: and, in many of the cases treated by the physician, the rescue from blindness is quite as certain, and almost equally evident, even to the unskilled observer. A legitimate means of confirming the title of our profession to respect and confidence, is found in the cultivation of a knowledge of those maladies which we are able to cure, quickly and safely, if not plea- * Rush's Lectures, Philad., 1811, p. 227. 28 santly. It is a worthy occupation to seek the means of preventing or curing diseases which have hith- erto resisted all our efforts: these may yet be subju- gated, as variola and scurvy have been. But, in pursuing such investigations, let us not forget to inform ourselves in regard to what has already reached comparative perfection. When reproached with what we have failed to do, we have a right, not only to speak of what we hope to accomplish, but to point to our present successes. By accumu- lating these, demonstrating, by repeated proofs, the superiority of his skill, the physician does much to maintain himself in the position which, by virtue of his title, he deserves to hold. Again, the diseases of the eye are not self-limited. In such, we rely upon a wise inactivity, — a careful surveillance that the efforts of nature are not frus- trated, — sometimes, on the observance of the pre- cept of Celsus, " Optimum medicamentum est oppor- tune cibus datus." But it is far different in ophthal- mic affections. We cannot feel justified in relying on the restorative powers of nature; for, left to themselves, the course of most of these maladies is not towards cure. Many of them, once establish- ed, have a tendency to advance steadily from bad to 29 worse, and to induce secondary morbid alterations, which, in turn, react, to aggravate the original affec- tion ; and thus, by slow degrees, the beautiful organ is defaced and rendered useless. Some others, in a single day or two, effect destruction of vision. Al- most invariably the physician must not remain an idle spectator. Nor need he hesitate from uncertainty as to his proper course and a fear that he may do harm. As a general rule, these maladies, properly understood, offer definite indications for treatment. In select- ing his therapeutic agents, he should be careful to proportion their activity to the delicacy of the struc- tures whose morbid conditions they are intended to remove; — otherwise he may aggravate the symp- toms instead of subduing them. Avoiding routine, he should make nice distinctions of constitution and circumstances, skilfully adapting means to ends. I have spoken of ophthalmic medicine as offering a degree of certainty in diagnosis and in the princi- ples of its treatment. It remains for the intelligent observation and reasoning of the scientific physician to bring it nearer perfection. Much may yet be done in devising new and efficient therapeutic methods, in diminishing the number of cases where operations are required to remedy the effects of pre- 30 vious disease, in elucidating the relations which these affections bear to the rest of the system. The progress which has been made gives us promise of new success for the future. In ophthalmic, as in other medicine, a repeated examination of facts and opinions, a renewal of observations, not only does not risk the loss of any known truths, but leads to the discovery of many others which are involved in the observations already made. Happily we are no longer bound by regulations founded on a belief that the six books of Hermes were a divine revelation, to which it would be sacrilege to add, and whose injunctions it were impious to disobey. It may be our privilege to add new wealth to the healing lore possessed and bequeathed by our fathers. From the day when Hippocrates made choice of Cos for the exercise of his profession; and as a physician, not as a deity, obtained the regard of its people, the progress of Medicine has been ever onward. From the slight knowledge which comprises all the skill of barbarous nations, — from the rude surgery of the Homeric and Ossianic heroes, — it has advanced to the importance of reckoning other sciences as its coadjutors and servants. We are to convert to use the materials which these are accumulating. The botanist and chemist have but described the objects 31 of their study, and the affinities they bear towards each other; — it remains for us to ascertain their relations to the human system. We have the highest motive to exertion in a gene- rous emulation to increase the sum of the knowledge which one of the principles of medical fraternity makes the common property of all its members. To the glory of our profession, its rules of ethics are adapted rather for the welfare of the public than to promote its own interests. Each medical man, ac- knowledging his obligation to impart to a confrere any knowledge he may have acquired, seeks to at- tain a high position only by surpassing others in his exertions for the general good. I have asked attention to remarks on a question of practical interest, believing that these would be more acceptable than any thing I could offer on the general tendencies, relations or duties of our profes- sion. Many of the reasons urged would apply with equal force in favor of the study of such diseases of other organs as are in a great measure local affec- tions, though intimately connected with the general system. The pathology of the eye has been alone referred to, on account of the important facilities and advantages to which I have already alluded; not because I question the obligation of the physi- 32 cian to become familiar, as far as he may, with every malady he is liable frequently to encounter in his changeful experience. For the last time we meet within these walls, where we have so often exchanged friendly greet- ings and enjoyed the benefit of familiar professional intercourse, — where for so many years we have welcomed our colleagues from other parts of the Commonwealth, and received their warm hand of fellowship. But, though the shrine be removed, may every sentiment of fraternity which has been cherished in this Temple, remain in our hearts. Re-united elsewhere, may the medical corps be animated by one spirit; and, banishing every un- worthy jealousy, strive to make its influence felt in the community, -— not merely through the talents and worth of individual members, but by untiring exertions for increased usefulness, scrupulous re- gard to whatever is honorable and praiseworthy in professional conduct, and an uncompromising cen- sure of every scheme of imposition or folly which may spring from the fertile brain of avarice or ignorance.