AN ADDRESS, DELIVERED BEFORE THE CLASS -»»i<- OF THE PHILADELPHIA MEDICAL ASSOCIATION, i AT THE CLOSE OF THE SESSION OF 1845. ALFRED STTLLE, M.D. LECTURER ON GENERAL PATHOLOGY, AND THE PRACTICE OF MEDICINE. [PUBLISHED BY THE CLASS] PHILADELPHIA: JOHN C. CLARK, PRINTER, 60 DOCK STREET. 1845. I ADVERTISEMENT. The following Address formed the concluding portion of the last lecture of the season, and was intended only for the Students of the Association. In permitting it to go before a larger, and more impar- tial tribunal, the Author feels it due to himself to state, that no other motive than a desire of awakening attention to the causes which de- press Medical Science in this country, could have induced him to render public so brief and imperfect a discussion of a theme on which it is not easy to dwell too long, nor too earnestly. ADDRESS, Gentlemen, This course, which was commenced nearly six months ago, has now reached its termination, and it only remains for me to address a few parting words to those who have been accustomed to meet me here. On the earliest possible occasion, the views I entertained of medical science, and a sketch of the proposed course, were laid before you. I endeavoured to show you that medicine was an inductive science; that it properly consisted of facts alone, and that its growth had been constantly retarded by the noxious influence of speculative philosophy. I essayed to prove, and to persuade you, that clinical study was a neces- sary and fundamental portion of a medical education, and that however versed you might become in the lessons of your teachers, and of your text-books, yet without clinical observa- tion your training would be incomplete, and the first years of your practice full of danger to your patients, and of mortifica- tion to yourselves. In view of the imperfection and in- adequacy of hospital instruction in this countrjr, I dwelt upon my obligation to relate the history of disease in a plain and 6 simple manner, to describe it faithfully, neither to add to nor take away from it a single feature impressed by Nature, to insist on the use of those remedies only which experience had shown to be effectual,—in one word, to render the lectures you were to hear, almost as practical as if they had been delivered at the bed-side of a hospital patient. But that you might understand what was meant by a disease, it became necessary to define disease in general; that you might comprehend par- ticular causes, lesions, and symptoms, it was indispensable that you should previously obtain correct general notions upon these points: in other words, that general should precede special Pathology, in the order of your studies. To this end the causes of disease were passed in review, then its course and terminations, the morbid anatomy of the fluids and solids, and the phenomena, mechanism, and results of inflammation, with organic lesions and degenerations. We next treated, at some length, of general Diagnosis, and dwelt upon its vast import- ance and usefulness, described the qualities essential to a good observer, and the proper mode of interrogating and examining a patient. The elements of Prognosis were then enumerated; after which the extensive subject of Semeiology, the science of signs, was entered upon, and all the prominent symptoms presented by the digestive, respiratory, nervous, and other systems, successively detailed. These discussions occupied about one-third of the whole course, a period which may have seemed unduly long to some of you, but perhaps not to those who reflected that they were introductory to a course of lec- tures on Special Pathology, designed to occupy at least three sessions like that about to close. After having disposed of the subject of general pathology, though in a far more sum- / mary manner than was requisite to do it full justice, we came to treat of particular diseases, beginning with those of the larynx, and describing in succession the inflammatory, orga- nic, and functional disorders, first of the respiratory organs, and then of the heart. In this second division of the course, an attempt was made to illustrate the principles before deve- loped, by adhering strictly to the known, and rejecting, with- out hesitation, the doubtful and the speculative, by assigning the highest credit to those authors only whose assertions were supported by proofs, and by denying all weight and conse- quence to opinions not so verified, whenever the proposition before us was susceptible of being proved by facts. Such is an outline of what has been accomplished during the past season. The work is certainly not one of great ex- tent, but you were forewarned that it would not be;—it con- tained very little addressed to the imagination, but you had been assured in the beginning that we regarded the practice of medicine as in itself a very prosaic business, however it might occasionally become suggestive of poetical thoughts or emotions;—it offered you no certain cure for any malady, and hardly a single formula or prescription, but you had been informed that it was no part of our object to discover for you a royal road to medical science, or invent a labour-saving machine for the student, but on the contrary, to persuade and constrain you to believe that all knowledge acquired without toil, is transitory and valueless, and that just in proportion to the mental labour you could be induced to bestow upon the subject, would be your tenacity in remembering, and your satisfaction in investigating it. The plan of the lectures was, 8 in some respects, unlike that usually adopted in this country, but it was such as is followed by the most eminent teachers in Europe, or rather, it was a feeble and imperfect imitation of the best models presented by the medical literature of the old world. Of this, too, you were apprized in the beginning. Throughout, it has been my sincere and earnest desire to give you the most accurate information, and that in the sim- plest and most unpretending style. If I have failed, let the blame rest where it of right belongs, upon the poverty of my resources, and the weakness of my skill, but not upon my in- difference to your interests, nor upon my having formed an inadequate conception of the serious and responsible duties of a public teacher. If I have deviated from the beaten track, it was because it seemed to lead to no good end, but rather into error; if I have chosen my models from a foreign land, it was not that I loved my country less, but truth and science more,— it was that I might labour with others to arouse the young men of the profession, to inspire them with noble aspirations, to imbue them with that love of knowledge which has made so many names illustrious and venerable,—that we might all feel the satisfaction of having taken one step forward in the march of educational improvement. Yet some one may perhaps object that these discussions about general pathology, and this severity of method in stu- dying particular diseases, were superfluous, because not re- quired to qualify a student for passing his examination at either of our great schools. If, indeed, they are not requisite for this purpose, we can only regret that those who are at the head of public teaching in this city and country propose so 9 low a standard of attainment to their pupils; but this cannot be admitted as a valid reason for the adoption of such a stand- ard here. The members of this Association do not profess to be mere substitutes or echoes of any set of teachers, but to give you the best instruction they are capable of imparting without regard to its accordance with the doctrines or the method taught elsewhere. They would fain believe that you who have voluntarily assumed the labour, and incurred the expense of attending a summer-course of lectures, have nobler motives and loftier views than can be wholly referred to a desire of obtaining the diploma of any institution, however respectable. They feel themselves under no obligation to tread in the footsteps of those who walk on level ground, when a path is before them leading to the very summit of the hill of science, and filled by the most eminent men of the age. It is time, gentlemen, that physicians as well as students should be undeceived, that they should learn how much too low is the standard of medical acquisition, and how fruitless will be all their efforts to elevate it without adopting the prin- ciples and emulating the example of our transatlantic brethren. There are demagogues amongst us who would have us be- lieve that we are, not only the freest and most enlight- ened people in the universe, but that we have also the wisest and best legislators, the most profound scholars, the most ac- complished men of science, the most skilful artisans, in a word, that we have reached the summit of political and social perfection. Soothed by this soft unction to our national va- nity, we are tempted to spend our lives in sluggish indolence, unambitious of distinction, or more greedy of receiving than B 10 of deserving praise. The harsh criticisms of foreign travellers upon our customs, or even their malicious caricatures of our peculiarities, are more wholesome, more fruitful of good, to us, than all such false and flattering tales. No man, nor nation, was ever the better for fulsome eulogy, and all real improvement, whether in communities or individuals, has been the consequence of their conviction of error, often of their punishment for faults. The very word improvement implies the passage from a defective to a better state. So that, y/if we would improve American medicine, we must first be- / come familiar with its errors and its defects. But we can only learn and reform them by comparing our system with the European, and promoting its resemblance to this latter. It is not possible to originate a plan of our own. In the mechanic arts, indeed, necessity is the mother of invention; but necessity does not form skilful physicians. Although a nation were quite cut off from all intercourse with the civilized world, it would necessarily make rapid advances in the me- chanic arts, until they had reached the degree of excellence required by the condition of the people. Not so medicine, nor the other sciences. These can be improved only by the earnest study of many generations of men set apart for this particular purpose. They need for their investigation intel- lects of a high order, and thoroughly cultivated. See to what perfection the dexterity of manual labour has attained amongst the Chinese, and yet in the " flowery land of the celestials" the healing art is almost as rude as it is amongst the savages of the southern archipelago. The necessity for medical skill is every where the same; it is just as urgent in the Indian's 11 tent, as under the " canopy of costly state," where royalty at last feels that its clay is no finer nor more durable than that of the beggar who lies at the palace gate. Every where the ingenuity of man suffices to clothe, to feed, to adorn, and to defend him; but in a few favoured spots alone has it power to heal his diseases. That power is not the achievement of one day, nor of one generation, nor of one people, but was of slow and gradual growth, from the dawn of civilization to the pre- sent time: gathered not from all the nations of the earth, but transmitted from one to another, and enriched in its passage by each successive nation of a long and glorious line. Trace the stream of medical science from its fountain. Two thou- sand years ago it rose in Greece, and widening with the lapse of time, received the tributary streams of Roman and Arabian learning, and then of modern Italy, France, Germany and England. Where has it deposited the vast freight of wealth it bore so long upon its bosom? Where upon its shores do we find the great monuments that attest its fertilizing and salu- tary progress, and its occasional destructive outbreaks? Where are the millions of tomes that record its long and eventful history? Where the immense receptacles of human wretched- ness from which these streams are filled? Where the wise, the gifted, the eloquent men, who trace out for all inquirers the origin and progress of every portion of this changing flood? Are these things here? I look around me and search in vain for those venerable colleges so well endowed by princely munificence, that even the poorest scholar need not fear to be driven from their gates. I see no statues to commemorate the learning and humanity of our great physi- cians ; no solemn halls where the dead still impart their wis- 12 dom to the living through the immortal page, and where the student may learn humility and modesty by comparing the present with ages that are gone before: no stately hospitals containing in one single city more than six thousand patients, and nearly all of them accessible to the student of medicine: no extensive systems of clinical instruction carried on by men trained in the several grades of medical practice, from their novitiate until they have grown grey in the public service. These things, which abound in Europe, are to be nowhere seen amongst us, but, in their stead, faint shadows of^hem all, partial and imperfect imitations, which, while they indicate our consciousness of the true source of medical knowledge, betray our indifference or aversion to making a full and effi- cient use of its benefits. Every one of our writers and teachers copies more or less the works of foreign authors. What others are published? What others are read? And yet there are to be found amongst the very persons who owe all their knowledge, and much of their skill, to European mas- ters, some who would make us contented with ourselves by assuring us of our proficiency, and even of our superiority to those who taught them all they know. But let them tell us what we have by right of discovery, that we can call our own; what, either in anatomy, physiology, chemistry, pathology, or therapeutics, that can entitle us to declare our independence of foreign teachers, to establish a national system, or to turn disdainfully from the hand whose bounty has hitherto sup- ported us. Far from counselling such ingratitude, I would have you still walk by the guidance of that sure hand, and thrive upon its overflowing wealth: I would have you follow still more closely the great leaders of the scientific world, and 13 by your earnest demands for more thorough instruction, con- strain those who have the conduct of medical education here, to conform themselves more strictly to the system of teaching pursued abroad, to enlarge and lengthen the course of study, and to insist upon much higher qualifications than are now required from aspirants to the Doctor's degree. You would have American medical science: the wish is noble and patriotic; but to fulfil it you must first rise to the level of European science, by making all its stores of know- ledge yours. Then only will you be prepared to cancel your debt to the old world; to repay with interest the aid she has extended to our new civilization in its time of weakness and of need. The more accurately and faithfully you walk in the path of its wise men, the more speedily will you overtake them, and the earlier will you be able to raise the beacon- light of American science to illustrate our native land as glo- riously as that which now disperses its life-giving beams from Europe to the ends of the earth. Yet it must be confessed, that if the same means are to per- fect medicine here which have advanced it in the old world, it may be long before their action will produce very import- ant results. The hierarchy or gradation in the medical pro- fession which has effected so much good in Europe, by pre- paring competent men for posts of honour and reward^ does not seem to accord with the spirit of our institutions, nor the long and laborious study, there exacted, to agree with our desire to appear and act upon the stage of life at the earliest possible age; nor can we expect that our governments should 14 set apart for clinical teaching, hospitals, in which the profes- sors, after twenty years' service, would run no risk of being thrust out of doors, unceremoniously, by a junta of insolent and ignorant politicians. Still, much may be accomplished. Already we have added something to the general stock of learning, and our contributions have been gratefully acknow- ledged. The names of Rush and Dewees are quite as well known, and as respected, abroad, as at home: and in the depart- ment of medical jurisprudence, two living authors, Beck and Ray, stand honourably at the very head of the list of writers on this interesting and difficult subject. The merit of the two former consists in their having given to the world admirable histories of what they had witnessed in epidemics of disease, in public hospitals, and in private practice; that of the two latter, in applying to a particular class of facts the rules of sound logic, and the principles of inductive philosophy. These are but heralds of a future multitude of scientific men, the first few stars in our intellectual firmament, which must usher in a countless and more brilliant train. Americans are neither dull-witted nor ignorant; they, on the contrary, possess abilities which need only a proper de- velopment and guidance to produce works as great as the world has ever yet beheld. But if we are contented to be- lieve that we have already reached perfection; that we have no faults to correct, no improvements to achieve; that we have nothing to learn from those whose opportunities for study, whose facilities for observation, whose security from molestation, are so far superior to our own, we shall, instead of gaining the respect, the esteem, and the admiration of 15 Christendom, become its laughing-stock, and the object of its contempt. Away with such self-complacent satisfaction ! Let us not only be conscious of our imperfections, but also acknowledge and strive to correct them. Let us diligently apply ourselves to the study of medicine as it is pursued in foreign countries; let us not be satisfied with that kind or that degree of know- ledge which is just sufficient to conceal our ignorance; let us thirst after all which can render us accomplished men, and which will once more make our profession worthy of being called "learned,"—a title which it now receives, indeed, by courtesy, but which it does not deserve. Let it not be objected, that this must be a work of time, and that its completion must be left for future generations. Granted that it is so; but the work must have a beginning, and although it may be, at first, but small, or almost imper- ceptible, it will advance and enlarge until the whole medical brotherhood shall celebrate its triumphant consummation. Why should there not go out hence, even from this nook and corner of the scientific world, from this little company of ardent and ambitious young men, some who shall become the Hunters, the Hallers, the Bichats of America, who shall re- deem us from our direct and enforced dependence on Euro- pean minds, and swell the catalogue of those illustrious names which belong to no one nation, but are the common property of all citizens of the great Republic of Science. If it should be my lot to inspire one soul with such high 16 aspirations—to make even one amongst you glow with a love of that severe but beautiful truth which I have ventured to set before you,—if I could anticipate that in your onward course to greatness, you might sometimes look back upon our connexion as the starting point in your career, the source of the first impulse to your upward flight,—then indeed would my satisfaction be complete; for although deeply impressed with the imperfections of my work, I should yet feel that in my humble efforts to do you good, I had not pursued an un- substantial phantom, nor toiled for a vain reward.