0 LAiJUrv0 AN INTRODUCTORY LECTURE TREATMENT OF DISEASE, DELIVERED BEFORE THE MEDICAL CLASS MASSACHUSETTS MEDICAL COLLEGE, BOSTON, NOVEMBER 3, 185 2. BY JACOB BIGELOW, M. D. PROFESSOR OP MATERIA MEDICA AND CLINICAL MEDICINE IN HARVARD UN1VERSITT, AND SENIOR PHYSICIAN OP THB MASS. GEN. HOSPITAL. BOSTON: TICKNOR, REED, AND FTELDS. MDCCCLI1I. PRINTED BY THURSTON, TORRY. AND EMERSON. Boston, November 5, 1852. To Jacob Bigelow, Professor of Materia Medica in Harvard University. Sir : At a Meeting of the Medical Class of Harvard University, held Wednesday, November third, we, the undersigned, were appointed a Committee to request, for publication, a copy of your Introductory Ad- dress, delivered at the commencement of the present course of Lectures. In the hope that you will comply with our request, We remain, very respectfully, your obedient servants, Joseph Clay Habersham, Algernon Coolidge, Richard H. Wheatland. Gentlemen, It is nearly eighteen years since I had the honor to deliver before the Massachusetts Medical Society, at their Annual Meeting in 1835, a Dis- course on ' Self-limited Diseases.' At that time, a system of active, and as it is sometimes called, 'heroic' practice, prevailed extensively in this city, and still more in some other places, under which it was common for physicians to absolve themselves from the imputation of neglect in the treatment of their patients, by an energetic course of measures, sometimes considerably transcending the necessities of the case. Since that period, it is believed that a more moderate, discriminating and expectant practice has prevailed in this city and vicinity, which has consisted in trusting more, in many cases, to the restorative powers of nature, and less to the interference of art, and at least in sparing the patient the unnecessary infliction of troublesome and superfluous remedial applications. It has sometimes been difficult to satisfy the friends of the sick, es- pecially in grave, dangerous, or protracted cases, that incessant and restless activity on the part of the physician is not the chief requisite in the treatment of most diseases. But of this error the public mind in this and other countries is becoming gradually disabused. The change has been mostly effected, in the intelligent and discriminating part of the com- munity, by the open and honest position taken by physicians entitled to confidence ; while among the credulous and uninformed, a like change has been brought about by the introduction of some nominal and nugatory forms of practice, which deceive and amuse the patient, while nature has time to rally, if it is capable of so doing. But the credit of this revolution in public sentiment is mainly due to the modern philosophic school of medi- cine in France, where the natural history of disease has been disentangled from the complicating influence of false considerations, and studied, like other sciences, on the basis of actual or approximative truth. I submit this Discourse, which is but a restatement of views which I have long entertained and expressed, with my thanks to yourselves and the Class for your kind attention. With great regard, your friend and obedient servant, Jacob Bigelow. Messrs. Joseph Clay Habersham, Algernon Coolidge, Richard H. Wheatland. INTRODUCTORY LECTURE. Of the sciences which have most occupied the time and labor of mankind, a certain number lead by their investigations to clear and positive results, and enlarge the amount of human knowledge by the discovery and promulgation of absolute truth. Another portion lead only to results which are probable or presumptive in their character, and which furnish to mankind rules of action, in cases where better lights cannot be ob- tained. To the former class has been given the name of exact sciences, and to the latter the name of pre- sumptive or conjectural sciences. Mathematics form an exact science, on the conclusions of which, when once known, there can be no difference of opinion. In like manner, chemistry and mechanics, astronomy and portions of natural history, are examples of exact sciences, the demonstrations of which, when once made clear, may afterwards be modified and enlarged, but arc never fundamentally shaken. On the other hand, the important sciences of ethics and politics, of commerce and finance, of government and speculative 6 theology, are inexact in many of their principles, as is proved by the widely different constructions under which men receive and apply them to practice. It would at first seem that the exact sciences were those most worthy the cultivation of intelligent minds, inasmuch as they lead to satisfactory, and therefore to gratifying results ; and because, in their more elevated departments, they involve and require some of the highest reaches of the human intellect. But in the opinions of mankind, as evinced by their practice, the opposite judgment prevails, and probably nine-tenths of the labor of educated and intellectual men, are employed on studies which are, in their nature, un- certain and conjectural. The cause of this great ascendancy in the attention given to the inexact sciences, is to be found in the vast and paramount importance of their subjects, and also in the difficulty of consummating their great ends. It is much more important to mankind to know how to avoid anarchy and crime, war, famine, poverty and pestilence, than it is to know that the planet Saturn has a ring, or that a lily has six stamens, that light can be polarized, or that potass can be decomposed. Yet while the latter propositions are susceptible of absolute demonstration, the former processes, which bear directly on human happiness or misery, are fre- quently removed beyond our foresight or control. The wisest men often fail to influence the destinies of states, families, and individuals, and the shrewdest calculators are baffled in regard to a coming crop, a i pecuniary crisis, a glut in the commercial market, or a change in the public morals. Nevertheless, the wise man conscious of superior talent, and the phi- lanthropist desirous of the public weal, and even the interested man who looks to his personal advantage and progress, must give themselves and their energies to studies which involve the immediate wants of their fellow-men, even though their best directed efforts should fail of the desired results. And the simple reason is, that if the best qualified minds decline to undertake this task, it will most assuredly be assumed by the ignorant and presumptuous. Preeminent among the inexact and speculative sciences stands practical medicine, a science older than civilization, cultivated and honored in all ages, pow- erful for good or for evil, progressive in its character, but still unsettled in its principles; remunerative in fame and fortune to its successful cultivators, and rich in the fruits of a good conscience to its honest vota- ries. Encumbered as it is with difficulty, fallacy and doubt, medicine yet constitutes one of the most attractive of the learned professions. It is largely represented in every city, village and hamlet. Its imperfections are lost sight of in the overwhelming importance of its objects. The living look to it for succor — the dying call on it for rescue. The greatest boons and the most important objects presented to our aspirations in this life, are not to be approached through paths which are straight and unmistakeable. The avenues to most of them are 8 shadowed by doubts or clogged with incessant obsta- cles. Next to the spiritual welfare of men, the preser- vation of their lives, the peace and safety of their communities, the acquirement and preservation of their worldly goods, are among the objects which take strongest hold on their desires. Yet grave doubts are justifiable, whether any precise means have yet been agreed upon by which these desirable ends can with certainty be attained. And if any one deems it a reproach on medicine that its cultivators have not arrived at a common faith and practice, let him consider whether the laborers in other fields, however honest their intentions, are agreed in their theological creeds and political platforms. Considering the great importance of the objects of medicine, the frequent and earnest appeals made for its assistance, and the vast sums annually expended in its remuneration, it is not surprising that disappoint- ment and complaint often follow the failures, necessary or unnecessary, of medical practice. " Man is of few days and full of trouble." Yet in the face of this acknowledged truth, he requests and expects that his physician will provide him with many days, and re- move at least his bodily troubles. This expectation on his part is reasonable or otherwise, according to the circumstances under which it is made. It is unreasonable if his case is helpless, and he is merely paying the debt of suffering and death which his mor- tal nature exacts. But it is reasonable and proper, if his complaint is of a curable kind, or if, whether cura- 9 ble or not, his physician has claimed and vaunted the power to remove it. Most men form an exaggerated estimate of the powers of medicine, founded on the common accepta- tion of the name, that medicine is the art of curing diseases. That this is a false definition, is evident from the fact that many diseases are incurable, and that one such disease must at last happen to every living man. A far more just definition would be, that medicine is the art of understanding diseases, and of curing or relieving them when possible. Under this acceptation our science would, at least, be exonerated from reproach, and would stand on a basis capable of supporting a reasonable and durable system for the amelioration of human maladies. Every young man who proposes to become a mem- ber of the medical profession, should ask himself whether he considers medicine a liberal and honorable science, to be followed for the good it may do to man- kind, or as a dishonest trade to be pursued for the purpose of profiting himself by the deception of his fellow-men. If he accepts his profession in the first sense, he will strive to understand his science in all its bearings, and practise it with conscience and fidelity ; if in the latter, he will put his conscience aside, and study only the low arts which entrap the credulous and unwary. With the trade of medicine I have nothing to do. Knowing that I address an ingenuous and cultivated audience, composed mainly of young men who are 10 looking forward to an honest and honorable place in professional life, I make no apology for proceeding to express my belief of the manner in which medicine should be practised and disease treated, for the re- ciprocal benefit of him who gives, and of him who receives its aids. Let no one deceive himself by believing that success, stable, permanent, honorable success, can be attained without knowledge of the great principles of the pro- fession and science of medicine. This knowledge must consist in an accurate acquaintance with the structure and offices of the human body, and the laws of its healthy condition. After these follows the science of pathology, involving the great and fundamental art of diagnosis, by which the diseases of the human body are detected and distinguished rightly from each other. The power of distinguishing diseases lies at the root of all correct and enlightened practice, and without it all medical action is empirical and fortuitous. There is no more pernicious error than for a physician to be- lieve that he can prescribe safely for the symptoms of a sick man, without understanding, in some measure, the nature of his disease. Symptoms are of various import, according to the seat of their origin and the nature of their causes; and if taken alone, without a correct interpretation of these attendant considera- tions, they often lead to a wrong result, or to no result at all. A patient not unfrequently sends for a physi- cian on account of a certain symptom which is dis- tressing him, and which may be, for example, a pain 11 in the abdomen, or in the head. Now a pain in the abdomen may arise from colic or peritonitis, from rheumatism or neuralgia, from dysentery, from calcu- lus, or from strangulation. And in like manner, a pain in the head may arise from a multitude of differ- ent and even opposite causes. Now it is well known that the kind of treatment which is effectual in one case, is pernicious in another; and he who prescribes for the symptom irrespectively of the cause, is quite as likely to do mischief to his patient as good, and quite as likely to destroy life as to save it. If the question be asked, what makes a great phy- sician, and one who is appealed to by his peers, and by the discerning portion of the public, for counsel in difficult cases, I would answer, that he is a great physician who, above other men, understands diagnosis. It is not he who promises to cure all maladies, who has a remedy ready for every symptom, or one remedy for all symptoms ; who boasts that success never fails him, when his daily history gives the lie to such assertions. It is rather he, who, with just dis- crimination, looks at a case in all its difficulties ; who to habits of correct reasoning, adds the acquirements obtained from study and observation; who is trust- worthy in common things for his, common sense, and in professional things for his judgment, learning, and experience; who forms his opinion positive or approx- imative, according to the evidence; who looks at the necessary results of inevitable causes; who promptly does what man may do of good, and carefully avoids 12 what he may do of evil. Examples are rare of this perfection, yet for an approach to such a standard of professional excellence, I would venture to direct your remembrance to the venerable ex-professor, fortunately yet among us, of the theory and practice in this Uni- versity. Every citizen whose capacity is able to reach the ordinary affairs of life, is aware that the persons most capable of discharging the common offices, or of exer- cising the common arts and duties of life, are the indi- viduals who have by talents, education and practice, become experts in those arts and duties; — and that, on the other hand, those persons who profess to have acquired knowledge by intuition, to have become learned without labor, and to have arrived by short cuts at results and qualifications which demand years of preparatory training, must be incompetent and treacherous sources of reliance. And it is the general admission of this truth which gives support and con- fidence to the various professions, arts and callings, to which men devote their lives. A little machine called a watch is carried about by most persons, and when this machine has stopped or is out of order, they do not lay their own ignorant hands upon it, but submit the case to the skill of an expert, who is known to be qualified to judge and act in such cases. It is the duty of this artist when applied to, to examine the interior of the watch, to ascertain by the use of his skill in what part the disease is situated, and to apply to that part the ap- 13 propriate remedy. If a spring or a chain is broken, it must be restored; if the wheels are out of gear, they must be put in place; if the hands only have caught, they have only to be liberated, and if the pivots are dry and rough, they must be oiled or cleaned; — and lastly, if the watch has had a destructive fall, if it has been crushed by being trodden on, if it has lain a month in the salt water, or if it is worn out by run- ning steadily for threescore years and ten, then the case is incurable, and the only palliative advice which the practitioner can render is, that the owner should procure a new watch, or reconcile himself to do with- out one. But suppose there resides in the place a watch doc- tor who prescribes for symptoms, and who, among other things, has a remedy for the symptom of stop- ping, and that this remedy consists in a certain kind of friction, shaking or manipulation, an ointment ap- plied to the outside, or an invisible particle of some nugatory substance inserted into the inside; and suppose that one or two watches in a hundred which had stopped by accident, should by accident resume their motions under such treatment, could anything but the most unmitigated folly draw the inference that such a person is entitled to become the accredited horologer to the community 1 What is so conspicuously true in the common busi- ness of life, is only an example of what is more vitally true in the practice of medicine. If a man has had the misfortune to get a shot or a stab in his body, he 14 does not need a doctor who administers a specific dose or a sovereign plaster for holes in the body; he wants a man who can tell him whether the wound has passed inside or outside of his peritoneum, and whether it is requisite for him to make his will, or to make arrangements for pursuing his journey. But the prescribing for symptoms in the dark is not the only instance in which false logic has entered into medical reasoning. It is not less absurd to suppose that disconnected events, which have closely followed each other, have therefore a necessary dependence upon each other. Shrewd, practical men do not thus govern themselves in the common affairs of life. A merchant about to send a ship to sea, endeavors to find a captain to take charge of her who understands navi- gation, who can keep his run and determine his place, who studies the weather and is on the lookout for a lee shore, and who in emergencies can judge whether it is necessary or not to cut away the masts or throw over the cargo. But suppose a man appears, and such have been, who announces that he has a specific bottle of oil with which he cures tempests, and by pouring a teaspoonful of which upon the waves, the storm is speedily made to cease'? Would any prudent owner intrust his vessel to such a man and on such grounds, even though he should produce a hundred certificates that storms had stopped in half a day, or half an hour after the application of his remedy? For these cer- tificates, if true, would only prove that in a certain number of cases, a result had followed by accident, 15 which common sense, and, if necessary, a thousand opposite cases would show had nothing to do with the pretended cause. What would be true of the apparent or alleged cure of a tempest at sea, is no less true of the pseudo-cures which every day take place in diseases which are self- limited, paroxysmal or recidivous in their character. There are doubtless living many men who believe themselves to have been cured half a dozen times of various diseases, of fevers and inflammations, of neu- ralgia, rheumatism, gout and asthma; and each time perhaps by a different remedy, but who on the next imprudence or returning period, are destined to find themselves feverish, neuralgic, gouty, or asthmatic still. Deceptions in medicine are occasioned not only by the dishonesty of charlatans, but quite as often by the well meaning credulity of other practitioners, whose intellect is impulsive or whose education has been un- duly curtailed. It is so flattering to a man's self-love to believe that his chance shots have sometimes taken effect, that physicians of regular position may pass their lives in mere speculative and random efforts at curing diseases, shutting their eyes against their own failures, and not allowing themselves to consider that in a certain portion of successful cases which they had failed to understand, the disease in truth got well without, or perhaps in spite of, their misdirected and embarrassing practice. Medicine is a great good and an unquestionable 16 blessing to mankind, when it is administered by dis- criminating and intelligent hands with sincerity and good judgment. It disappoints expectation, and fails to accomplish its mission, when the agent who dis- penses it falls into the mistaken resource of professing infallibility, and of raising hopes which he knows not how to accomplish. No man is deemed to be safe in his worldly affairs who is afraid to look into his own pecuniary condition. Neither is a physician safe in his practice or his reputation, who is afraid to face the case of his patient in all its bearings. That man is most to be relied on who looks calmly and under- standingly at the emergency before him, who knows the import of signs, and deduces from them the proba- ble tenor of coming events; who is aware of the great truth that all men must die, but is also aware of the more gratifying truth that most sick men recover, and who, in particular exigencies, inquires of his reason and his knowledge, in which of these two immediate categories his patient is placed, and how far the event of the case is within his control. He will then inter- fere or he. will wait, he will act or he will forbear, as he only knows how who can form a correct verdict from the evidence before him, and who knows the immeasurable good or harm which hangs on medical practice. The vulgar standard of medical character depends very much on the supposed successful result of cases. But this is not the true standard, for the best physi- cians as well as the most popular practitioners, often 17 lose their patients, and even their own lives, from com- mon diseases; while, on the other hand, the most injudicious treatment, and the most reckless exposures are not unfrequently survived. Laennec and Bichat, two of the most distinguished lights of modern medi- cine, died of the very diseases they were themselves investigating. Preissnitz, the prince of modern em- pirics, himself a robust peasant, died of premature disease at the age of fifty-two, in the midst of his own water-cure. It is wrell known, that the most thronged and popular places of resort for grave, difficult, and intractable cases, are those from which there are most funerals. On the other hand, men support life in certain cases under every extreme of opposite treat- ment, under ultra-depletion and ultra-stimulation, under heroic practice and nugatory practice, under " hot drops" and cold douches, under drachm doses of calomel, and imponderable doses of moonshine. Clot Bey and his two or three associate Frenchmen, entered a plague hospital at Cairo in the height of the epidemic. They shut themselves up in the concen- trated atmosphere of the infection, they remained in contact with dying patients, they wore the shirts of those who had just expired, they inoculated them- selves with the secretions of pestilential buboes,'— and all to no purpose. They were alive some years after- wards, and quarrelling with each other for the glory of their hair-brained enterprise. Four thieves in the plague at Marseilles freely prosecuted their robberies in the infected houses of the dead and dying ; and the 3 18 aromatic vinegar which has immortalized their pro- phylactic practice, was very probably an impromptu invention brought forward by them to procure their pardon from punishment. The humility which we may learn from the limited influence of our art on the health and lives of man- kind, is probably a far safer guide to a correct practice, than the fanatical confidence with which unenlightened ultraists of every sect carry out their respective dogmas. In a sphere of action where some good may always be done, and where much harm often is done, and " fools rush in wrherc angels fear to tread," it is well to consider some of the rules which may lead an honest inquirer after truth to the nearest attain- ment to a correct judgment and practice. Supposing, what I would fain wish might always happen, that the physician is duly and thoroughly imbued with knowledge of his science, the first great question which presents itself in every case or emer- gency, is that which involves the diagnosis. This being established, the practitioner is enabled to avail himself of the lights of reason and experience in regard to a correct course of therapeutic proceeding. But it often happens that the nature of the case cannot be made out in one, or two, or three interviews with the patient, and we are obliged to wait for the gradual development of diagnostic symptoms, as a judge and jury in a like case would be expected to postpone or wait for the arrival of witnesses. It is a mistaken pride which leads physicians to commit themselves by 19 an oracular guess at first sight, which the events of the succeeding day may show to have been erroneous. Moreover, if from the obscure character of the case, or the imperfection of our science, diagnosis is impossible, we should then so generalize our treatment that we may include what is possible of good, and exclude what is probable of harm. Having settled, as well as our means admit, the pathological condition of our patient, the next ques- tion is that which regards the probable tendency of the disease if left to itself. Attention to this point is of high importance, since it will prevent us from neglecting our patients in grave and dangerous affec- tions, as well as from annoying them with useless appliances in short, safe or unimportant cases. Many diseases are insidious in their origin. The nervous imbecility which has its foundation laid in modern schools, the slight cough and evening flush which herald approaching phthisis, soon get beyond the reach of medical means, unless seasonably detected by the wary eye of the practitioner. A simple dis- charge from the ear may terminate in deafness, and an ulcer of the cornea in loss of sight. A protracted intermittent at length undermines the health, and neglected syphilis ends in a miserable death. Cases like these require prompt and energetic interference on the part of the practitioner. On the other hand, diseases which are light in themselves, and tend to speedy recovery, as common catarrh, hooping cough, varicella, and a host of other things, if they occur in 20 healthy subjects, and are not complicated with graver affections, may safely be left to themselves, or treated with the mildest remedies and cautionary measures. Another most important question, exercising the hopes and fears of every practitioner, from its connec- tion with reputation, safety and life, is that which relates to the curability of diseases. Is the disease amenable to medical treatment, or not? If the case is of a recoverable character, and happily a great majority of our cases are so, the physician should anxiously and carefully have recourse to the recorded authorities of his science, and to his own personal ex- perience. In doing this he should beware of implicitly trusting those who have published only the favorable side of their practice, preferring to build up a tempo- rary reputation rather than to promulgate unpopular truths. And in analyzing his own experience, he should equally beware of hasty generalizations, of impressions made by remarkable examples, rather than by aggregates of well observed and duly ar- ranged cases, from which alone impartial and correct inferences are to be drawn. In accordance with such views, we shall find many cases which are, for the most part, capable of being arrested or broken up by the interposition of remedies. Thus the grave and various symptoms which result from an overloaded stomach, are at once removed by the action of an emetic, or sometimes of a laxative • colic in like manner yields to opium or to purgatives ; syphilis is cured by mercury, and sometimes without 21 it, and certain inflammatory attacks apparently yield to seasonable depletion. Moreover, in other cases which cannot be thus arrested, but which, from their nature, must run a destined course, it is generally ad- mitted that the safety of the patient may be promoted, or perhaps the duration of the case abridged by reme- dial treatment. This is believed to be true in regard to evacuations at the commencement of febrile and inflammatory diseases, and to a multitude of other remedies applicable in various cases. But on this subject it is extremely difficult to obtain decisive and satisfactory knowledge. It involves a question, the settlement of which is to be approached by exten- sive and contrasted numerical observations, a large portion of which yet remain to be made, although we have valuable contributions and examples on many subjects. On the other hand, when we know that a case is self-limited or incurable, we are to consider how far it is in our power to palliate or diminish sufferings which we are not competent to remove. Here is a most important field for medical practice, and one which calls for an exceedingly large portion of the time and efforts of every physician. When we consider that most diseases occupy, from necessity, a period of some days or weeks, that many of them continue for months, and some for years, and finally that a large portion of mankind die of some lingering or chronic disease, we shall see that the study of pallia- tives is not only called for, but really constitutes one 22 of the most common, as well as the most useful and beneficent employments of a medical man. In the use of efficient remedies, much depends upon deciding the proper stage or time, to which their employment is applicable. Some curative agents can with propriety be used only at the outset of the diseases, and if this opportunity is lost, the remedies are afterwards less effectual, and perhaps even inju- rious. Venesection in the early stage of certain acute diseases, may be productive of great good; m the middle stages it is of less benefit, or of none at all; and in the latter stages it is injurious and inadmissi- ble. On the other hand, wine and opiates, which are strongly contra-indicated in the first stage, are after- wards not only tolerated with impunity, but in certain cases are taken with decided benefit. But, gentlemen, the agents which we oppose to the progress of disease, may, by excessive or ill-timed ap- plication, become themselves the pregnant sources of disease. Every prudent practitioner is bound to con- sider the effect and tendency of the remedy he is using, and to inquire whether the means employed to counteract the existing disease, are not, in their turn, likely to produce evil to the patient; and if so, whether the evil will be greater or less than the disease for which they are administered. The sudden healing of an old ulcer, issue or eruption, may be followed by symptoms more serious in their character than those which have been removed. Many remedial processes, if employed in excess, or with injudicious frequency, 23 result in permanent injury to the patient. The ha- bitual use of active cathartics, although attended with temporary relief, seldom fails to bring on or aggravate a permanent state of costiveness. Large and often repeated blood-letting, tends to the establishment of debility and anemia in some subjects, or of reaction and plethora in others. Opium and other narcotics arc, in themselves, if abused, fertile sources of disease. The modern crying evil of polypharmacy, and over- medication, is profitable to the druggist, habitual to too many physicians, and annoying, if not detrimental to most patients. On account of these and similar considerations, much discretion is needed on the part of the phy- sician to enable him to judge rightly of the kind of treatment which it may be safe and proper to employ, and of the degree and amount of that treat- ment, and of the requisite length of time for its continuance. Medical practice, in many cases, points to the direct substitution of a positive good for a posi- tive evil; but unfortunately, in other cases, it admits only of a choice between evils; — and in these cases not only the knowledge and experience, but also the judgment and common sense of the practitioner, are put in indispensable requisition to lead him to a correct issue. It is wrong to suppose that the opportunities for doing good in medicine, are limited to the effect of specific remedies, or to the application of drugs and instruments. The enlightened physician surveys the 24 whole ground of his patient's case, and looks for the presence of any deleterious agencies or unremoved causes of disease. Many morbid affections which have resisted powerful remedies, cease speedily on the discovery and removal of their sustaining cause. A child is often sick from an error in the diet, health or habits of the nurse or mother. An individual fre- quently suffers from the quality and quantity of his habitual food or drink, or of his exercise, air, occupa- tion or clothing. The starved infant and the overfed gourmand, the drunkard and the ascetic, the pale student and the emaciated seamstress, require removal and reform, not drugs and medicines. A patient dies of phthisis in a confined office or a damp northern climate, who might have enjoyed long life in an active occupation, or a more pure and temperate atmosphere. On the other hand, men fall victims to the fevers and abdominal diseases of the south and west, who might have escaped disease by a timely removal to the north. It is as necessary in many cases that the physician should inquire into the situation, diet, habits, and occupation of the patient, as that he should feel his pulse or explore his chest. It often happens that the disordered state of the one cannot be corrected until the other has been previously set right; and a little dietetic instruction, or even moral advice, is more serviceable than a technical prescription. In regard to their duration, their probable issue, and their susceptibility of relief, the physician may profitably divide his cases into three classes; those 25 which are curable, those which are temporarily self- limited, and those which are incurable. In the first class, or that of curable diseases, are to be included those morbid affections which we know, or have rea- son to believe, are under the control of remedies, so that they can be arrested, or abridged, in duration. For the most part, acute inflammatory diseases, when not of fatal intensity, are mitigated by depletion and the antiphlogistic regimen, more or less actively enforced, according to the degree of violence. Spasmodic diseases, on the contrary, are influenced by opiates, antispasmodics and tonics, and by the removal of their cause, when it can be discovered and remedied, as in cases of dentition, indigestible food, &c. Sympathetic diseases are to be addressed through the medium, organ, or texture which is primarily affected. Thus, a headache depending upon a disordered stomach, or a hysteric affection upon irregularity of the uterine function, are to be treated under this view of the sub- ject. Hemorrhages and other morbid discharges, are to be dealt with by removing the cause when practi- cable, by diminishing vascular activity, or by quieting the discharging surfaces with opiates, or contracting them with astringents. There is one class of curable diseases which are controlled chiefly by specific reme- dies, being in some instances suspended, in others radically removed. Thus, gout is relieved by col- chicum, and intermittents by quinine and bark. Scabies is cured by sulphur, syphilis by mercury, goitre, as we are informed, by iodine, and various 26 chronic eruptions by arsenic and corrosive sublimate. The foregoing examples will serve to illustrate, not only the power of medicine, but also the great variety of grounds which should govern medical practice, and the importance of an intelligent diagnosis, as well as a knowledge of therapeutic means. In the next subdivision, or that of self-limited diseases, we include those " which receive limits from their own nature, and not from foreign influences, and which, after they have obtained foothold in the sys- tem, cannot in the present state of our knowledge be eradicated or abridged by art, but to which there is due a certain succession of processes, to be completed in a certain time, which time and processes may vary with the constitution and condition of the patient, but are not known to be shortened by medical treatment." Examples are abundant, and are found in typhus and typhoid fever, measles, small-pox, hooping cough, dysentery, and many other diseases of lighter or graver character. It is with regret that we are obliged to acknowledge the existence of a third class, that of incurable dis- eases, which has been recognized in all ages as the opprobrium medicorum. It includes the long train of internal morbid degenerations, malignant and chronic, by tubercle and granulation, by atrophy and hypertro- phy, softening and hardening, scirrhus, encephalosis ossification, concretion, contraction and dilatation, with their various consequences of phthisis, emphy- sema, dropsy, epilepsy, paralysis, and a multitude of 27 intractable disorders, in which organs are disabled, functions destroyed, and life itself rendered incapable of continuance. It is obvious that in the three foregoing classes of disease, very different modifications of treatment are required. In curable diseases, our remedial measures should be prompt and energetic in proportion to the emergency of the case, and the certainty of benefit which is to follow their employment. In self-limited diseases, our treatment must be of the expectant char- acter. It consists in doing what we can for the com- fort and safety of the patient, avoiding useless and troublesome applications, watching against accidents and complications, and in waiting for the salutary operations of nature. In those maladies which are in their nature incurable, we are obliged to confine our- selves to the palliation of suffering, and the removal of causes which may aggravate the disease. Such I believe is the true exposition of the powers and duties of every medical man. The dignity of our science, and the responsibility of our profession, re- quire that we should form just views of the extent of our capacity and duty, and that we should not shrink from avowing them to the world. Our science, imper- fect as it is, has achieved as much as any similar science for the prevention, alleviation, and removal of the evils which it combats. Let us not bring it into disrepute, by pretending to impossibilities, by assert- ing what cannot be proved, and by professing what human art is unable to accomplish. A new era will 28 dawn upon medicine when its faithful and enlightened cultivators shall more constantly devote their time and their efforts to enlighten the public mind in regard to the true mission and powers of their science; and when they shall leave to charlatans and fanatics, the doubtful and dishonest game of unfounded profes- sional pretension.