THE RELATIONS 1 OF THE Medical Profession TO THE STATE. BEING THE ANNIVERSARY DISCOURSE DELIVERED BEFORE THE MEDICI L SOCIETY OF THE STATE OF NEW YORK, FEBRUARY FIFTH, 1879. *D. B. St. JOHN ROOSA, M President op the society. »,hs NEW YORK: PUBLISHED BY OjBDEK OF THE SoCIE'lT. 1879. THE RELATIONS OF THE MEDICAL PROFESSION TO THE STATE. The country in which we live is still a new one. Many of our forests are primitive and much of our soil is uncultivated. Even in our oldest States we may see regions upon which man, by his residence and labor, seems hardly to have made a sensible effect. We have scarcely any of the garden-like cultivation of England, we have no wood-parks like Ardennes and Fontaine- bleau, no gray towers on our river banks, and few of the broad and hard highways over which Moltke's armies marched to Sedan and Paris. In our vast country there is a constantly recurring impression of newness, and, in a certain sense, of roughness. I am not unmindful of what wTe have achieved in the way of invention, manufacture, commerce, and culture. I merely7 wish to recall to your minds a fact that we are all per- haps inclined to forget, namely, that we are still a new people in a new land. We cannot inherit the fullness of cultivation of the older peoples in our intellectual work any more than in the cultivation of our soil. Our relations as individuals or as guilds and professions, to each other and to the government, must of necessity be different from those wbich obtain among older nations with their centuries of history and of tradition. In Europe there has been time for many things to arrange themselves into a refined system. The profession of medicine 2 in a country like England, or France, or Germany, is sensibly influenced by these conditions of age and fixity, and is in cer- tain established relations to the State, which make unnecessary many of the discussions into which we are constantly drifting. The ordinary and extraordinary necessities of our govern- ment, have left little time for such minor matters as the determination of the relations to it of a class which the State has practically declared to have no formal connection with the governing powers. The process of arrangement is, however, now going on. For the next hundred years the people of the United States will devote much time, not only to the refinement of their material condition, to their highways and hedges, their fields and lawns, bat also to the relations of the various guilds into which the people are di- vided, to the State to which all give allegiance. May I then beg your attention to a consideration in outline of the relations of the medical profession to the State ? I have said, deliber- ately, that we must be engaged for the next hundred years in establishing and perfecting them, for I have no idea that in our generation we shall do much more than begin a work which can only be completed in many decades of time. No dream of a homogeneous, vast, organized, and catholic body, untormented by schism or disorder, in settled relations to the civic authorities, has passed over my mind. I do not anticipate that the legislation of this or of any subsequent session of our ancient and honorable body will create a medical Utopia, but I hope that each one of its meetings will accomplish some- thing toward the establishment of the medical profession in such proper relations to the State as shall redound to our ad- vantage and honor, as well as to that of the commonwealth. I am not one of those who believe that we must model all our affairs after those of the Old World, that what is right for England, Germany, and France must of necessity be right for the United States ; but I hold that there must be many things in which we shall improve upon the ways of the older nations, and that, from the very nature of things, there must be many ways in which our modes differ from theirs. I will consider the relations of the medical profession to the State under the following heads: 3 I.—As Witnesses to Aid in the Detection of Crime, ok the Breaking up of Nuisances. II.—As Defendants in Suits for Malpractice. III.—As Educators of the Physicians of the Future. IV.—As Managers of Institutions for the Care of the Sick and Injured. V.—As Protectors of the Community from Quackery. VI.—As Sanitary Advisers to the Commonwealth. I.—It is probable that the singular contradictions of some of our medical experts have excited the wonder of laymen and a sense of shame in medical men. The laity have sometimes asked if there are really no fixed rules for the determination of the existence of metallic poisons in the human body; if there is no evidence of insanity that may be clearly shown to a jury ; if there is no standard as to what is a perfect cure of a fracture; and if it be not possible for the physicians of New York to agree as to whether the noise from an elevated railway is an injury to the nervous system. We know, and all intelligent lay- men know, that there must always be different shades of opin- ion upon the same subject, in a science so unsettled and progres- sive as our own; but nobody yet knows why it is that experts can always be found who honestly believe that no antimony ever was in a certain stomach, when it has been already discovered by supposed reliable authority, or why one man is pronounced to be raving mad by Professor A., and competent to take charge of vast estates by Professor B. Neither does any man know why Dr. X. believes that all broken limbs ought to heal with- out shortening, while a professional brother, of equal position, positively states that no legs ever unite without some lessening in length. Neither do any of us probably understand why a large number of physicians are induced to say, that '* perverted mental and moral action, cerebral exhaustion, insomnia, hys- teria, chorea, mania, paralysis, meningitis, and decay of nutri- tion," will be largely promoted by life along an elevated rail- way, while other authorities state that "medical literature," ac- cording to their belief, " does not afford a single instance of any of these diseases being caused by noises such as are pro- duced by the cars on an elevated railway." 4 ( The system in our law that allows able and zealous lawyers to coach and pay their own experts, until they have made honest partisans of them, is certainly vicious. The State should summon, the State should pay experts, and they should act as associate judges, to aid the real judge in getting the truth before the jury. The plaintiff and defendant should un- doubtedly have the right of putting their case before the medi- cal experts, and exercise a choice in selecting them; but the medical man should receive his honorarium from the State, and never be put in the position, as an expert, of being a witness for one side. Then the physician, surgeon, or chemist would go upon the stand, so far as it is possible for human legislation to attain such an end, without fear and without the idea of favor. Napoleon asked Du Bois to treat the Empress of France in labor, as if she were a peasant woman in a hospital, instead of a sovereign in a palace. The medical man should be placed in a position where he may be able to treat a medico- legal case as he would a dead body under his scalpel. The subject of the adequate payment of medical experts comes, of course, under this head. As matters now stand, physicians may be obliged to make long journeys, and give, for a mere pittance, valuable opinions, the fruit of years of toil- some observation. It is the opinion of many, which is shared by your speaker, that the whole subject of payment of those who work for the government should be carefully looked over, and that such an examination will show that a great and powerful State ought to pay its servants so well, that the best men may be claimed and secured for its service. Certainly experts should not be taken away from their ordinary duties without a compensation that will, at least to some considerable extent, recompense them. This society has already taken action upon the subject of payment for expert testimony, by appointing a committee to ask the Legislature to consider this subject. II.—As' Defendants in Suits for Malpractice. It is a matter of mortification that there should be any ne- cessity for such a relation of the profession of medicine to the State as this. But physicians are unfortunately not exempt 5 from the frailties and faults of humanity, and they must ex- pect to answer at the bar of j ustice for any crimes they may commit. In what I have to say, there is no claim for any im- munity from punishment for neglect of duty or culpable ig- norance on the part of a medical practitioner; but I shall simply attempt to show how, under our present system of inquiry, medical men are at the mercy of ignorant jurors and unscrupulous lawyers. It is often the case, that after medical men have given their time without fee or reward, they are called to account on a charge of malpractice that has no other founda- tion than that the patient did not recover in the manner that he or his friends thought he ought to have done. I frankly admit, however, in the outset, that we ourselves are in a measure to blame for the tone of expression about the work of physi- cians, which is somewhat prevalent among the people. It has often pained many of us, I am sure, to hear a medical practitioner boast, even in the presence of laymen, of cures that he had made, when another man, his peer, had blundered. This idea of considering the result as largely due to personal and extraordinary gifts, is the basis of the notion among the laity that the attending physician is to blame if an eye be lost, a fractured limb be shortened, or if a patient die from disease. " If Dr.----had not done so and so," or " if he had done so and so," in the common phrase, the patient would not have died ; or, as I have often heard it much more strongly put, " I have always thought that Dr.----killed that person." This is no fancy sketch. It is as flippantly and commonly asserted in or- dinary social circles, that physicians often kill patients by neg- lect or stupidity, as that plumbers put in defective material and leave holes in waste-pipes. In a famous play of Moliere's, one of his characters constantly jeers at the faculty in such phrase as this: " All the excellence of their art consists in pompous nonsense and idle babbling, which give words for reasons and promises for performance."—toute Vexcellence de leur art consiste en un pompeux galimatias, en un spe'cieux ba- hil, qui vous donne des mots pour des raisons et des promesses pour des effets. No criticisms are more uproariously received from a stage, than such as these, even in France where our calling has always been held in high esteem. Moliere well 6 expresses the tendency of society, and in our own time some of its most cutting sarcasms are directed upon the ignorance and want of skill of medical men. The speaker knows of a social discussion of the merits of a celebrated oculist, which was ended by the serious assertion of a man not at all unfriendly to the subject of remark, in the following way: "Well, he has put out a great lot of eyes." To lightly accuse a man of being a liar, or a thief, is still considered a disgrace in any society in our land; but a doctor is imputed with malpractice in as free and easy a manner as the most trifling peccadillo is charged upon a servant. Bat we, as a profession, should first clear ourselves from any complicity in this kind of detrac-' tion, before we turn upon those who lightly bandy charges against medical men. If each of us would ever guard his brother's honor as his own, and promptly avow a disbelief in the charge of malpractice which is so frequently brought to him by a patient who is about to change his physician, the flippant tone often observed in society in regard to the services of medical men would soon be changed to one of respect. Skill of hand, years of experience in the observation of medical cases, are sometimes temptations to lead men to suppose that they can tarn away the hand of disease and death when others have failed ; but a little sober thought of our own impotence when the inevitable time has come, will soon lead us to an aversion to any special claims for healing power. Let us feel the sad truth, that there is a destiny that shapes the issues of life and death, rough hew them as we may, and no pressure of need for daily bread, no desire for success and fame—above all, no wish to triumph over another physician, will ever cause us to put our- selves in the attitude of tradesmen praising our wares, or of skillful mechanics promising to repair or build. Our posi- tion should be rather that of experienced, careful, and cool- headed mariners, well provided with compass, chart, and lead, who hope by the blessing of God to bring the good ship into port, but who do not claim to control the fog and the storm, which, in spite of the most careful navigation, are sometimes the destruction of a gallant ship and crew. There is need for a remedy for some of the worst features of these suits for malpractice. One of the States of our country, 7 which is always in the van in any progressive political or social movement, has already passed a law which does away with the system of coroners' juries as it now obtains in New York. By this new law of Massachusetts, the office of coroner is abolished. In his stead is a medical examiner, and not until his investiga- tion as to the causes of death is ended, is there any calling upon the civil power, which then appears, if necessary, in the form of the district attorney and a justice. In our State the coroner may not be even a physician, and he may be a very ig- norant man, while the coroners' jury is usually obtained in the easiest way possible. When we remember that serious medical questions are very often involved in the decisions of such a coroner and such a jury—questions affecting the reputation and freedom, perhaps even the life of a physician—we do not wonder that one State has at last done away with the bad system to which New York still clings. Let me give one instance from many that could be cited of the workings of a coroner's jury in oar State. A physician in New York city was recently sum- moned as a witness in the case of a man who had died from acute meningitis resulting from an inflammation of the middle part of the ear. The relatives of the deceased had avowedly set the investigation on foot, because they believed that the physician who was called as a witness, had caused the death of the man by a surgical operation which he had per- formed upon the drum membrane. The friends and the jury were of a low type of unlettered day-laborers. The coroner had never received a scrap of medical education, and very little of any other. The theory of the investigators was that the instrument used to open the abscess in the ear, had entered the brain and caused a fatal bleeding. It was shown that the man walked away from the place where the operation was performed, much relieved of severe pain, and that he returned two days after, expressing himself as much benefited. Three days after this he died, not having seen the surgeon after his second visit. The jurv examined and cross-examined the physician who had performed the operation as to his skill and character, and several witnesses of the same intelligence with the jury testi- fied very freely as to their opinion of the cause of death. The animus of the jury was so marked that the coroner was obliged 8 to resort to some urgent advice to prevent them from bringing in a verdict which would have compelled the surgeon to appear before a grand jury. Although there was not one shadow of evidence of malpractice, but rather of proper and kindly treatment in a hospital, where as usual all the services of the attending surgeons are absolutely without fee, the jury finally brought in the following remarkable verdict: " We the jury come to the conclusion that----came to his death by a rupture of the blood-vessel or small brain, or with some instru- ment used by doctors unknown to the jury." Medical men, suspected or accused of negligence or want of skill, should be protected from the wrong of an examination of their case by those who have none of the knowledge necessary for the conduct of such an inquiry. The profession has long since asked for protection from another fault in our system, which allows a certain class of lawyers to take up cases of alleged malpractice on speculation, as it is called. Both in this coun- try and in England, physicians are quite often put to great expense and loss of time, in defending themselves from frivo- lous charges, which usually fall to the ground even when brought before a jury of men utterly unacquainted with the science of medicine. The law can probably give us but little relief from these attacks, for the fall right of appeal to a court for redress should never be unduly restricted. But the law can see that, if tried we must be, it shall be by " careful judg- ment of our peers"—a right that should never be denied to one of Anglo-Saxon blood. More than this, we can come to such a correction of senti- ment in our own profession, that it will be impossible to find medical instigators of unjust suits. Most of these frivolous cases, unfortunately for our fair fame, depend upon the willing- ness of some medical men to lightly assert that a case has been improperly treated, and that in their skillful hands the result would have been different. One of our remedies for unjust attacks upon the faithfulness and skill of medical men must be found in such an elevated tone of professional sentiment as will prevent us from imitating the vilest of birds, that are said to foul their own nests. 9 III.—As Educators of the Physicians of the Future. Although, from the very early history of this country, the community has taken an active interest in education, and even in special education—that of ministers, lawyers and teachers, scarcely anything has been done for the instruction of medical students except by the individual effort of the men who elected themselves to be professors in the medical colleges which they founded. In the State of New York, at an early date, there was an attempt at a medical college which should be a depart- ment of King's College, now Columbia. In this the European idea of responsibility of the faculty to a Senatus Academieus was a feature ; but this state of things did not continue, and to- day not one of the leading medical colleges of the State is any- thing more than a first-class educational establishment, owned and practically controlled in all its details of financial manage- ment and appointment of professors, by a body usually of seven men. They are at the same time proprietors and teachers, just as much as " John Jones, A.M.," is proprietor of and professor in " the famous and large boarding-school situated on the banks of the Hudson, in full view of the Catskill Mountain House and the haunts of Rip Van Winkle." As a matter of course, the an- nouncements and circulars of these colleges betray their private character, and offer the most flattering inducements to their patrons, while their buildings are surmounted by flagstaffs from which float their emblazoned banners. The contrast between the announcements of medical colleges in this couutry and the catalogues of the Universities of Vienna, Berlin, and Stras- burg, with their sober, unpretentious detail of the names of teachers and the facilities open to the aspirant for medical knowledge, is not at all creditable to our sense of propriety and good taste. All that the State has to do with these col- leges is to prescribe that students in them shall study three years, that they shall be twenty-one years of age when they graduate, at which time they shall also be possessed of a good moral character. From the beginning to the end of the course of study, the men who teach in our medical schools are abso- lutely masters of the situation, and the ultimate judges as to the qualifications of those whom they send forth. The State vir- 10 tually says, and the community still more positively: While we have an interest in the quality of our lawyers, and we see to it that the various religious bodies look after the character of their ministers, and we educate teachers at the public cost, we leave the whole business of making medical men to the private institutions where they are instructed. It is true that in some of these colleges there is a titular connection with so-called universities, bat he who makes the acquaintance of the manag- ing boards of these institutions soon finds that they have an actual contempt for the idea that it is any part of the duty of a board of councillors or regents to look after the charac- ters or acquirements of the men whose diplomas they are sign- ing. They are not at all unwilling, however, to publish the list of medical students in long columns, and upon the credit of it take to themselves the name of a university. But to these directors medical education is entirely a private affair. So far from encouraging a close union between the departments really united to the governing board of the college or university, they have been known in some cases to actually tax the medical department for the honor of being connected to such a step- mother. It is greatly to the credit of the medical colleges of this State that they have maintained medical teaching at a high standard, in spite of such a system and such an indifference and hostility as have been delineated. Whatever may be said to the contrary, any exact examination will show that the medi- cal teachers of the State have always been foremost in the efforts to extend sound knowledge. Actual count will show that their books furnish the most by far of those published on medicine, and that their papers greatly outnumber those presented at the meetings of medical societies by their fellow-members of the profession. Apt as is the medical press to decry medical pro- fessors, it may be safely asserted, that the temptations of their irresponsible position have not overcome them, but they are among the chief promoters of scientific culture. Something better than a desire to advertise themselves and to secure a pe- cuniary reward, has usually animated the men who have founded and maintained our colleges. Admitting all this, there are so many evils in the present system, as it obtains in all bat one of the medical colleges of this State, that a change is 11 imperatively demanded. We need an examination for admis- sion, a graded and fuller course, and a more rigorous final examination. The only problem to be solved is, how shall we secure these ends % I think, if we turn our eyes again to the State of Massachusetts, we shall find there the only certain means of reforming our medical colleges. But I hold that the State cannot undertake the work. In a country where there are sects, and dangerous sects in medicine, where men who are ignorant of anatomy and physi- ology are rated as physicians, the work of an examining board appointed by political authority, that owes allegiance to the people—to whom all so-called doctors, whether sons of seventh sons, bone-setters, patent medicine makers, or graduates of colleges and hospitals, are alike—would be a farce. Whatever may be proper for England and Germany, the United States are not yet ready for an alliance of medicine with the State. Neither do I believe that this society or any other society can successfully undertake the supervision of the medical colleges. The older members of this society can tell us of the failures of the system of censors, and we know how the last law in regard to examinations by county societies has succeeded simply in legalizing every kind of a nominal physician. But observe what has been done by the President of Harvard Uni- versity. AYith great ability and far-sightedness he has brought its medical school into close and responsible relations to his Board of Trustees as a part of his scheme of raising a college to the dignity of a universit}7. He has taken it out from its independent position and made it, like academic, law, scien- tific, dental, and theological departments, a part of a whole. That once done, professors once independent of the favor of students, the existence of the school no longer dependent upon numbers, all needed reform became possible. Harvard has led where we must sooner or later follow. The Univer- sity of Pennsylvania has also taken a step, although not a very long one, in the same direction, and the medical college at Syracuse as well as the medical department of Union University adopt the Harvard plan. The sentence against the voluntary and irresponsible system has been pronounced by the higher sense of the medical profession. There is some 12 delay in carrying it into effect, but of the final result there can be no doubt. This intimate connection of medical colleges with boards of trustees is only to be secured by a recognition of the true status of medical departments of universities and by endowment. The State, as such, however much we may ask of its individual members, should not be expected to assist, even much less to en- dow, medical colleges. Neither special education nor special charity should be the function of a republican, as contradistin- guished from a paternal government. We have not passed through one hundred years of independent government to at last be bound in the swaddling-clothes of infancy. Besides, if there were no other good reason against governmental endowment, it would not be safe for our catholic profession to seek and secure an alliance with the State until the average legislator knows the difference between the man who is a physician and the man who calls himself one. The profession itself should secure these endowments. We should begin to use our powers with wealthy and influential laymen, and secure for the cause of sound medical education its share of public regard. It is our own fault that even intelligent men know nothing of the subject, and consequently have no interest in it. A prominent man in one of our cities, himself one of the governing board of a college with a medical department attached, whose diplomas he was in the habit of signing, once told a teacher in that department that he supposed medical students graduated after one year's study; and another member of a governing board of a university in this country, once said that he had yet to learn that medical education formed any part of university training. If educated laymen do not know that a real university should have a medical school as a part of it, and that they have a vital interest in the quality of doctors sent oat to practise among them and their families, we must teach them all this. Then they will endow our schools, and give them the facilities, and cause them to make the ad- vances demanded by our time. Here is the kernel of this whole matter of reform in medical education. Anatomical, chemical and physiological chairs, and laboratories in colleges, and cliuiques in hospitals, should be properly, although not 13 extravagantly endowed, so that medical schools may be main- tained even without excessively large classes. The present necessary laxity in admissions, and in final examination, fairly overwhelms the land with physicians. Many of them are only so by title. What was adequate in requirement for 1779 is not sufficient for a hundred years later. Our good medical colleges have all resorted to makeshifts in reform, but all the new demands are voluntary and not obligatory, so that if a man chooses he may graduate in .our State with large acquirements; but if he do not so choose, or if he is not able to do so, he may get a diploma with very mod- erate attainments. I am not one of those, however, who be- lieve that a proper system will of itself tarn out good medical men, or that any amount of education will compensate for want of brains. A man may be graduated from a college here and study abroad, and yet be utterly incompetent to practice med- icine; while a college education and foreign travel are of ines- timable value to nearly all who are fortunate enough to get them and wise enough to appreciate their advantages. When John Hunter, who could barely read and write at twenty years of age, heard that he was reproached by a rival with being ignorant of the dead languages, he replied : " I would endeavor to teach him that, on the dead body, which he never knew in any lan- guage, living or dead." Our colleges must be made better then, by being considered as one of the objects of philanthropic aid, as well as art galle- ries, observatories, schools of science and of theology. I doubt if one hundred thousand dollars has ever been contributed in this State toward the cause of medical education. But how shall this overtaxed and heavily burdened community find the means for this new call upon its benevolence ? By sparing from its useless expenditures that which is here so much needed. In the little churchyard at Stoke-Pogis, marked only by his name, lie the remains of the immortal man who wrote— '' Can storied urn or animated bust Back to its mansion call the fleeting breath ; Can honor's voice provoke the silent dust, Or flatt'ry soothe the dull, cold ear of death ? " 14 In spite of these words, which should have an influence where- ever our tongue is known, our beautiful cemeteries, where may ever grow the rose, the violet, and the forget-me-not, con- tinue to be disfigured by costly sarcophagi and monuments, and to be associated with funereal pomp. The money thus used could well be given where it might aid to lengthen life or mitigate disease. The State has yet much to do in the matter of legalizing the dissection of unclaimed dead bodies. This is a difficult matter to manage. The chief trouble lies in the natural repugnance of the human race to the mutilation of the body after the spirit has left it. We bury our dead with a tenderness and care that show how we reverence the temple in which the soul was enshrined. The humblest and the poorest share this sentiment with the noblest and most affluent. Yet, without the dissection of dead bodies, without the careful rehearsal of surgical operations, anatomical knowledge and skill in surgical work—knowledge and skill necessary to save life, are impossible. The sugges- tions of some wild sentimentalists in our own profession, and of tender-hearted journalists, that we shall get our knowledge and skill from models, is simply puerile. Who would know- ingly trust his life or limbs to a surgeon who had never traced out the nerves, muscles, and blood-vessels on the dead body, but who had only studied anatomy on wax models ? The pub- lic wras deeply stirred last winter by the desecration of the graves of honored public citizens in a distant State. Indigna- tion waxed hot because some of the underlings of a medical college had robbed the abode of the dead. None of us have aught to say in extenuation of the misdemeanor of those who vio- lated the sanctities of the grave. Yet we majr urge the State of Ohio, and all other States, to facilitate the necessary study of anatomy and surgery among students and practitioners by allowing medical colleges to freely use all the unclaimed dead bodies, of which there are, unfortunately, many on this sad earth. Let us, as a profession, never for a moment permit the notion to become popular, that we can attempt to teach or to practise without a knowledge of the human frame derived from actual study of its structure in the dissecting-room and on the post-mortem table. 15 IV.—As Managers of Institutions for the Care of the Sick and Injured. There is a widely diffused belief among business men and lawyers, that physicians and clergymen have very little of the ordinaiy tact necessary for the financial care of large interests. It is undoubtedly true that men thoroughly devoted to the high matters of the care of morals and health cannot at the same time give much attention to strictly business affairs. But, in any economical plans involved in the care of the souls and bodies of their two charges, the two professions show an astuteness, and manage their affairs with a success, that may safely invite comparison. A devotion to religion or science is not at all incompatible with correct business ideas as to the erection and maintenance of a church or hospital. Some of the great minds of the world have been famous for the ability with which they carried out the details of their calling. Samuel Smiles says that it was because the Duke of Wellington was a first-rate business man, that he never lost a battle. People are beginning to get over the notion, if they ever entertained it seriously, that true genius despises the wisdom of this world. A man is none the less a cool surgeon, a wise physician, because he attends to his own financial affairs and those of his hospital with care. There is really nothing in the idea that a physician may not be as good a manager of economical and financial interests as a lawyer or a banker. Not because he is a good physician, but because to be a good physician he must first be a good man. The history of an average business career in this country is not so flattering that the class which represent it can afford to claim an exclusive knowledge of how to manage hospitals and asylums. The record of the management of the army hospitals during the civil war, by physicians and surgeons of the army of the country, is a complete answer to those who would put away medical men from the care of their own. Distrust of the business and executive capacity of medical men, mingled with a notion that they are contentious, are the real reasons for the almost universal exclusion of medical men from the governing boards of hospitals and dispensaries. Yet this distrust is not 16 founded on facts. Physicians may have been unfit managers of affairs when they were men of the cloister and the library, when they spent their time in reading the theories and fancies of other men, or when they devoted weary nights to the cru- cible and the discovery of the elixir of life. But we have changed all this. The long gown of the study and the gold- headed cane of the consulting-room have been, put aside for the dress and equipment of an active life. Medical learn- ing now depends upon close study of the human frame itself, and not of ponderous folios—upon practical experiments in the laboratories and exact observation in the sick-room by the aid of all kinds of physical instruments, and not upon the development of fancy-woven theories that had no basis except in the disordered minds of their inventors. The well educated and well trained physician of to-day may manage a hospital with a facility quite equal to that of a man learned in dry goods, politics, or the stock board. It is evident that the genius of our time has not only changed the character of the medical profession, but also enlarged its sphere to a remarkable degree. We are being educated up to the re- sponsibilities which the demands of the age have thrust upon us. Neither the community nor physicians have yet come to a full appreciation of these facts. Hence, the old con- dition of things obtains. Hospitals are built without medi- cal or sanitary advice, by gentlemen who have acquired their notions of hygiene by years of study of day-books, ledgers, and real estate investments, interspersed with a grand tour of Europe, during which they have visited the badly planned hospitals of Paris; and they are officered by philanthropists who think the only safe way for those who value sound finan- cial management, as well as peace and quietness, is to keep the doctors out of boards of direction. Some of the hospitals erected by laymen, in the full light of what was shown by the hospitals built by the profession during the late war, are very far from being models of economical and healthy struc- ture. The cost of taking care of patients in some of the grand buildings of England and America is equal to that of board at our first-class hotels, with the services of a nurse and a consulting and attending physician included in the bill. Put physicians 17 in fair proportion on the boards of erection and management of hospitals, and we would soon change all this,'and inaugurate iu civil hospitals the system that has given to the medical officers of the United States Army a wide and enduring fame. V.—As Protectors of the Community from Quackery. In the discussion of this part of our theme, there is at the outset a difficulty in definition. There is no difficulty with us who are of the profession, but in the minds of those who are not in our calling. An average man, even a college-bred man, is very apt to consider medicine as an experimental art, with not much, if any, science about it; for operative surgery he may have some respect; but medicine is so largely a matter of guess-work, that to many such men the opinion of a person who has no exact knowledge of the human frame is as valu- able as that of the most learned and experienced practitioner. When such a man is seriously ill he waits eagerly for his phy- sician, and professes great estimation of his aid. When merely ailing, however, he does not hesitate to prescribe for himself, or to accept the prescriptions of any person whom he may chance upon, and who is willing to tender him advice. He will also visit Saratoga or Richfield, and enter upon a course of treat- ment by means of the waters there, without dreaming that it might be well to take the advice of a physician before resort- ing to such active medicines as are contained in Congress or sulphur springs. I think it is Mark Twain who tells the story of a sea-captain who had a chest of medicines, with a book, and various remedies numbered according to directions in the book. On the occasion of the illness of one of his sailors, the captain found, on consulting his manual, that No. 14 was the medicine required. No. 14 happened to be out, but on reflec tion he concluded that a combination that would make those numbers would do as well. He accordingly prescribed 10 and 4, and was verv much surprised that a burial at sea was the result of his scientific experiment. Very few people venture to o-ive opinions in regard to purely mechanical employments, unless they are trained to them; but the whole community, educated and ignorant alike, are quite willing to prescribe for disease, and to explain physiological phenomena. At not very 2 18 long intervals onr newspapers give us highly colored -sketches of the woman who has been unable to leave her bed for years, who cannot use her hands naturally, and yet does wonderful things with them; who sees with her eyes closed better than those of us who have ours open, who lives without eating, and who is altogether a supernatural being. Sympathizing friends gather around the poor hysterical and epileptic sufferer, the victim of disease of the nerves and of excessive sympathy, and as they go away proclaim the modern miracle. The press and the clergy vie with each other in their sensational accounts, and in some instances they are aided and abetted in this work by members of our own profession. If such cases as these come to be regarded as real exceptions to the laws governing dis- ease and the functions of the body, we may as well put the dial marking medical progress back to the dark ages, and assimilate our views of God's government of the world to those of Cotton Mather and his fellow witch-executioners. These things show how far we are from a rational view of the science of medicine, and the cognate subjects. They also show how much remains for us to do in creating and maintaining a healthy public senti- ment. A connivance with wonder-mongers, and miracle- workers greatly delays the day when our science and art shall receive the full respect of the laity. I have no time to adequately discuss the subject as to whether there is or is not a science of medicine. That there is, we know; that there is a science both in the administration of drugs, and still more perhaps in refraining from giving them, we are all sure; but how are we to expect a community that for centuries has had thrust upon it, without protection from the State, races of bone-setters and clairvoyants, and, still worse, of men and women without even a rudimentary knowledge of the structure and functions of the human body—a community whose ears have been deafened by the din of the sects as they have vaunted their systems of cure—how can we expect them to define a charlatan or quack, when they still believe that a knowledge of the practice of medicine is a divine gift, that may, like the poetical genius, be developed in the brain of an illiterate plow- man, or be the heritage of a seventh son of a seventh son ? While we may not ask the State to endow medical schools, 19 we may certainly expect that it will protect its citizens from well-defined quackery. It certainly cannot discriminate in regard to modes of treatment, when there must always be such honest difference of opinion. The State cannot catalogue the drugs that may be used, or name the doses; but it is the bounden duty of a Government that cares for the welfare of its inhabitants, to see to it that no one is allowed to prescribe for diseases who has not furnished evidence of a satisfactory knowledge of anatomy, physiology, and chemis- try. It should also interfere to prevent the sale of so-called patent medicines, and of adulterated medicines and food. A State that will not do this should, in all consistency, allow mad dogs to run in the streets, lunatics to go at large, and gunpowder to be stored in every house, and leave its rail- road crossings without guards or signals. There would be no abridgment of the rights of the citizen in such a protec- tion. If a man does not know enough to guard himself from the advice of those who prescribe for a machine of which they do not know the mechanism, the State should interfere to protect him, just as it provides the commonest means for public safety, by means of the police and the army. What is wanted is a board of examiners, made up of the best men from the colleges and the profession, who shall determine, not the orthodoxy of a candidate as to the doses of drugs, or the uses of cold water and vegetable medicines, but as to whether he has been well grounded in the structure and functions of the human body, the remedies for poisons, the rules for action in emergencies, and the principles of diagnosis, a knowledge of which will, at least, protect his patients from scandalous mal- practice. If, however, civil service reform has not reached a point that assures us that the board can be appointed solely on the ground of professional fitness, and without the taint of partisan politics upon it, we are better off as we are now, with no guards whatever except those that we set up among our own members. VI.—As Sanitary Advisers to the Commonwealth. This is perhaps the most comprehensive and important of any of our relations to the State. It is the one now receiving 20 general attention, and there is a prospect of its proper ad- justment. There are, howrever, still many obstacles on the part of the powers that be, in the way of yielding to physicians as a class, even in matters purely sanitary. We here meet the same difficulties that we have already discussed under other heads. Physicians are still very largely regarded as fit only for the necessary but narrow walk of their calling—in prescribing for disease that has already broken out, and for taking charge of accidents that have already occurred. Preventive medicine, which you and I are most anxious about, is not yet fully ap- preciated by our law-makers. A physician is often considered as a kind of fire-extinguisher, to be sent for in case of a con- flagration, but as rather a useless member of the body politic when there is no actual crisis. We are not singular in being thus unappreciated. Lawyers are the most valuable and most occupied in the prevention of litigation ; soldiers are chiefly useful to avert war; and yet advocates and soldiers are very often regarded as of no use except in the court-room and on the battle-field. To think in this way is to wdiolly misunderstand the work of the professions. There is a kind of exultation in the remark that a physician has not made a professional visit to the household during the year. So far as immunity from actual disease goes, this delight is as proper as it is natural, but many a man and woman who smile at the idea of the need of medical advice, are walking surely to the edge of a precipice from which sound counsel might keep them. The physician should have the same prerogative in the State as in the family, and no man can be properly said to be a conscientious physician who does not, if allowed, have a gen- eral, vigilant, but not impertinent oversight of the hygienic arrangements of the household of which he is the sanitary in- spector and adviser. There should be a board of health in every county and in every town, and this board should have no man upon it who has not a medical, scientific or legal education. Not a school-house, not a jail, not a hospital, not a sewer, should be built unless competent sanitary advice, with power to en- force it, be given. There are many other thino-s of which physicians should have the oversight, which are now entirely 21 neglected. As instances of these may be mentioned the super- vision of the hygienic condition of prisons, public charities, private and public insane asylums. A supervision that is con- nected with the ordinary management of these places is not sufficient, however careful and conscientious may be the officers. Experience has shown that routine habits may be acquired, which only vigilant governmental supervision will prevent. The attention of the medical profession has been lately called, both in Europe and our own country, to the great proportion of people who have no proper idea of the difference of colors. Examination has shown that this proportion exists among rail- way and steamship officials. When we cross the ocean and sail up the English channel with its thousand of craft, as we are in our cabin unconscious of danger, the man on the look- out may not be able to tell a red light from a green one, or we may have been journeying on the railway to this capital behind an engineer who is equally incompetent for his important duty. We should follow the example of Sweden, and demand such a searching investigation as will put in other positions men whose visual defects now render them useless and dangerous in places where colored signals are used. In the future no steamship or railway should be allowed to employ a lookout-man, switchman, or an engineer who cannot satisfactorily submit to the tests for the perception of colors. Here is room for reform. Here is work for the closing years of the nineteenth century. What a change in public senti- ment is to be made, to bring about a proper state of things ! And yet how necessary! In one of the most beautiful hill regions of this country, or of the world—in a spot where the sunrise and sunset are such as must shine upon the Delect- able Mountains—a place where the mists that roll away be- fore the sunlight disclose green forest-covered mountain-tops that are the glory of the land—in a spot where the water leaps clear as crystal in cascade and waterfall, or meanders along the valley in the placid brook, man had so neglected the necessary hygienic arrangements that the foulest and dead- liest materials at one time contaminated the water and the air, and with this brought disease and death. The hotels were closed, their visitors scattered—some of them dying, however, before 22 the source of evil was detected. Nor is this a solitary in- stance; it "is only a specimen of what is constantly occurring. Epidemic upon epidemic has visited communities, notably in the South, fever has constantly broken out in beautiful valleys, chil- dren have become the victimaof spinal distortion, sight has been impaired and lost by the thousand of cases, and all for the want of scientific and medical care. What may be done in preventive medicine is perhaps no- where better shown than in the exemption of our city of New York from cholera and yellow fever. A wise system of quar- antine, rigorously carried out by an intelligent and incorrupti- ble physician with great executive ability, while it has not re- stricted the freedom of commerce, has averted epidemics from a large population. Some time since, three representative physicians called upon the mayor of a large city to ask him to appoint a doctor upon a board having charge of the public schools. Among the score or more of lawyers, politicians, and business men, who occupied the chairs, there wras not one medical man. Several political reasons were given for declining this modest request, but the chief one, of a general character, was that physicians could hardly be found who could give the time from their occupations to this preventive work. Assuming that this was an honest reason, it shows a marvellous ignorance of the functions of medical men, and a supreme want of appreciation of the fact that should be evident to thinking people, that the physicians of our time have as one of their chiefest functions that care of the community which shall prevent deformity, disease, and death. The recent epidemics of yellow fever at the South are start- ling appeals to the State and to the medical profession. Can nothing be done to prevent this awful waste of human life ? Must this grief of a desolated population continue to arise '( The experts in sanitary science have told us that thousands of the deaths at Memphis, Grenada, and New Orleans were in consequence of municipal violation and neglect of well known sanitary laws. Somebody has blundered. From what we know in our own State of the powerlessness of medical authorities in such matters as the cleansing of sewers and streets, it is to be feared—indeed, it is known, that Tennessee, 23 Mississippi, and Louisiana, like New York, are not at all awake to the necessity for medical supervision of the housekeeping of all towns and villages. The principle that, in order to promote public health, the town, the village, and the city must be as rigor- ously cleansed as the body of an individual, must be taught by us, until the people everywhere understand that the care of the public health is one of the highest duties of the officials of the State. How can we hasten the day ? It is a mistake of the poets that a good cause must certainly prevail. Many an honest and wise effort for the advancement of the human race has been strangled in the hour of its birth. Many a persecution has successfully stamped out a growing crop that promised a blessing to its time, and has left only blood and desolation in the mark of an iron heel. However good a cause, it needs advo- cates and an impartial judge. It is true that the eternal years of God belong to truth, but it is also true that error and sin are often triumphant for a time that is interminable to its victims. "No; things will never right themselves. 'Tis we must put them right." Two things must be earnestly seen to by us, if we will hasten the day when the medical profession shall assume its true rela- tions to the State. They are unity of action and a jealous re- gard for our reputation as a profession. In one of the conflicts of opinion in the medical profession that so often occur in all large bodies, an astute and experienced layman of New York remarked to a medical man who wished to secure his aid on one of the sides which had been formed in the profession: " If the gentlemen of your profession could simply agree with each other, you could rule the city." It is certainly true that, if on the sanitary and medico-legal questions of the day we were united, we could accomplish in a few years that which, with our present modes of action, will require de- cades. When Benjamin Franklin was endeavoring to arouse the Colonies to resistance to the exactions of Great Britain, he circulated among the doubting and divided patriots an emblem of a serpent cut into thirteen parts, and accompanying it the motto," Join, or die." Whether we are dissevered or united, we 24 shall still exist as a profession. So long as man is subject to accident and disease we shall form an integral part of the com- monwealth, but the prominence and proportions of that part will depend upon our individual integrity, our wise delibera- tions, when assembled in council, and our unity in action when our deliberations have closed. We are an isolated class as we labor in the tenement-house and the hamlet, the hospital and the palace, always with the suffering and the dying, harassed and worn by our self-imposed weight of human care, and our voice may seem only as one crying in the wilderness, as we lift it for reform; but as we gather to-night, the honored and ex- perienced head of age side by side with the enthusiastic smile of youth, the dullest can see, that while we are without pomp, banner, or emblem, we may yet be a power in the State. If we desire to be an influential body in the affairs of the State, we must always be jealous for the honor of our craft. The achievements of individuals must become the property of the whole profession. They should be as tenderly and safely guarded by us as are the battle-stained and bullet-torn flags of regiments that have been through the valley of death. No personal considerations should ever induce us to decry the fame of men whose accomplishments have given American medicine an honored name all over the world. If there be nakedness to cover, let us step backward filially, with our faces turned, while we throw our garments over it. With united front, let us who struggle for the prolongation of life and the mitigation of disease, continue our advance in the same column with those who, by cultivating the soil, by humane and wise legislation, and the administration of law, by the finding out of many inventions, by the inculcation of the prin- ciples of morality and religion, contend for a land and a time when «the wilderness and the solitary place shall be glad for them, and the desert shall rejoice and blossom as the rose," and the Eternal God shall wipe all tears from the faces of men. ' ■-,v"ir';