ADDRESS DELIVERED BEFORE THE AMERICAN MEDICAL ASSOCIATION. BY ALDEN MARCH, PRESIDENT OF THE ASSOCIATION. A EXTRACTED FROM THE TRANSACTIONS OF THE AMERICAN MEDICAL ASSOCIATION. PHILADELPHIA: COLLINS, PRINTER, 705 JAYNE STREET. 1864. ADDRESS. GENTLEMEN OF THE AMERICAN MEDICAL ASSOCIATION Precedent, and long established usage, have well nigh rendered it of binding authority for the presiding officer to address you on the present occasion: and as we are assembled in this great commer- cial metropolis to transact business of the greatest importance- no less than that which concerns the life, health, and well-being of the great family of man-let it be our first, as it is our highest and most sacred duty, to lift up our hearts and voices, in thankfulness to a kind Providence, from whom we derive our being, to whom we are indebted for our continued existence, and for the privilege vouchsafed to us of gathering together in numbers this day equal to those of similar occasions, even in the palmiest days of this august Association. May we not then, in a spirit of Christian faith and true philan- thropy, invoke the guidance and example of the great Physician, whose mission, while on earth, was to heal the sick, to restore the blind to sight, to unstop the ears of the deaf, and to raise the dead from their graves ? With these high and holy aspirations deeply impressed upon our hearts, shall we not be encouraged to hope that all of our de- liberations, while engaged in consulting upon those interests which are best calculated to disseminate comfort and happiness to human- ity, may be characterized by the same brotherly love and social ties of professional friendship which have on all former occasions per- vaded our ranks, and which have been the chief element by which we have been held together, emphatically, as the great organization of medical science-" The American Medical Association ?" I appear before you this morning, gentlemen, in the double 4 capacity of presenting you with what may be called an inaugural and a valedictory address. It hardly need be explained how it becomes my duty, and, I may very well say, my distinguished privilege to address you on this interesting occasion; It was the spontaneous will of my professional brethren when convened at the last anniversary meeting of this Association. The office of presiding over your deliberations was unsought and unexpected; and unprepared as I was to discharge the duties -delicate and responsible as was the task-nevertheless, to pro- mote and to preserve harmony in our organization, and to comply with the repeatedly expressed wishes of over-partial friends, I have made an effort to fulfil them, according to the extent of my ability. I regret that this distinguished honor had not been conferred upon one1 who had older and higher claims to it-upon one with whom the idea of a medical convention originated, and to whom we are, in a great degree, indebted for the organization of our present delightful association. I trust the time will yet come when all local and sectional jealousies, and all suspicion of disloyalty shall have been dissipated, that the originator of this grand and truly noble association will be remembered and duly honored. It is meet and proper that a full share of credit should be awarded to the prime mover of any great scientific or benevolent enterprise -any movement that is designed to extend the blessings of the healing art as broad and as free as are the maladies " to which flesh is heir." An appropriate share of honor may also be attributed to those who may have aided in a work so noble, so glorious-and it is exceedingly gratifying to the speaker to know that he has been thus historically and honorably identified with the origin of this great enterprise.2 When the first President of this Association3-the Nestor of American Medical Science-was inducted into the presidential chair, he remarked, "I can find no language to express the depth of my gratitude-it is the most precious of all the honors I have ever received, as spontaneously conferred by my own brethren." If such deep gratitude filled and swelled the bosom of the vete- ran of other high official and professional honors, how much more 1 Dr. N. S. Davis. 2 See " History of the Am. Med. Assoc.," by N. S. Davis, D., p. 23. J Nathaniel Chapman. 5 befitting will it be for me to render unfeigned thanks for this mark of confidence and respect! When we take a glance at the names of my illustrious prede- cessors in office-of Chapman, of Pennsylvania, Stevens, of New York, Warren, of Massachusetts, Mussey, of Ohio, Moultrie, of South Carolina, Wellford, of Virginia, Knight, of Connecticut, Parsons, of Rhode Island, Pope, of Missouri, Wood, of Pennsylvania, Pitcher, of Michigan, Eve, of Georgia, Lindsley, of the District of Columbia, Miller, of Kentucky, Ives, of Connecticut; and last, though not least, of the gem of a Jewell of Pennsylvania, I fear that such a constella- tion of medical lights may be quite too imposing for me to attempt to imitate, or even to make an effort to follow. There is, however, some consolation to be derived from the fact that all true pictures are made up of lights and shades; and that the latter only aid in developing the excellency and beauty of the former. It is in this respect that the background of the picture may be regarded as performing a subordinate, although an essential part of the representation. It will be perceived that all sections, at least the cardinal points of what we were once proud to call the United States-the East and the West, the North and the South-have been represented in the Presidential chair of this Association; showing, therefore, that, in former days at least, there was with us no political, no social North or South, East or West; but that we were one then and indivisible. And may we not devoutly pray to be one now and ever more, in our political, professional, and social relations ? The indications of the times, we think, encourage us to hope for a happy reunion, ere long, as broad and as cordial as in any of our former gatherings. Without doubt will be remembered by many who are here to-day, the hearty welcome and spontaneous demonstration in the clapping of hands, when the names of dele- gates were called from the States of Virginia, Missouri, Tennessee, and Maryland, as we were last year convened in the great Prairie City of the AVest. Located, as I am, one hundred and fifty miles north of this great commercial emporium, in what might be called a country village in comparison with the teeming population of the London of America-a city not less distinguished as the patron of the arts and sciences-nevertheless, I can but feel that some historic interest attaches to the seat of government of the Empire State. Frigid and inhospitable as our location might lead one to infer as 6 to the true character of our natures-suffer us to say that we have warm and sympathetic hearts, which as readily respond and vibrate to the calls of patriotism and'benevolence as those of any other portion of this Republic. It is to our legislators that we are indebted for the incorporation and pecuniary aid of the New York State Medical Society-a society which has numbered, and still numbers among its members some of the most distinguished of our profession-a society in which originated the call for a "National Medical Convention" in 1845, now nearly twenty years since, which was the germ of the great and powerful " American Medical Association." The aim and object of the Convention was to enlist concerted and harmonious action upon the subject of improving and elevating medical education. It will be remembered that at the Convention held in this city in May, 1846, a committee of nine was appointed to prepare and present the subject in a suitable form for the action of the Conven- tion. A member1 of that Committee submitted a preamble and a set of resolutions, the first of which so simply and beautifully expresses the points aimed at, that no apology will be required for presenting it on this occasion, merely with a view to refresh our memories upon the objects of this Association. "Resolved, That it is expedient for the medical profession of the United States to institute a National Medical Association, for the protection of their interests, for the maintenance of their honor and respectability, for the advancement of their knowledge, and the extension of their usefulness." At this stand-point it may be interesting and instructive for us to look back upon our past labors, to see how much, and how well we have succeeded in accomplishing the objects embraced in this brief resolution. We have, indeed; instituted, or rather established an American Medical Association, which has contributed to protect our interests, and to " maintain our honor and respectability." We have adopted a wholesome code of medical ethics, especially designed to accom- plish such an end. And the record of the various papers on the many different subjects of the healing art, which have been pre- pared and discussed in this Association, will indicate how far our 1 Dr. Hays, of Philadelphia. 7 medical knowledge has been advanced, and the amelioration of the moral and physical condition of those around us will show' how far we have succeeded in "extending our usefulness." It has been well remarked that "in unity there is strength." This principle has been most emphatically illustrated in the united labors of the medical profession of these United States. Physiological and pathological subjects have been thoroughly investigated-Medical and Surgical diseases; Chemistry, Pharmacy, and Materia Medica; various specialties; statistics of life and death; and enlightened sanitary measures best calculated to pre- serve health, have each and all received a due share of professional culture, as the numerous published volumes of our Association -will fully attest. The subject which has most engrossed the attention of the medical profession, especially that of this Association ever since its organization, is the best means of elevating the standard of medical education-a subject well worthy of all the time and talent that have been devoted to it by some of the most able and honorable men of our profession. That there is pressing need of improvement in the standard of knowledge for the practice of physic and surgery, none will deny; and equally true is it that the great mass of the profession de- sires that the standard of medical knowledge should be elevated -should be commensurate with the demand of public sentiment. The thoughts and study of my predecessors in office-of com- mittees on medical education-of the lay members, and of pro- fessors of medical colleges, have been faithfully and zealously devoted to the consideration of the best means to be employed for the accomplishment of this grand and all absorbing subject. I am fully aware that it will be of but little avail for me to make an attempt to perform what abler and more learned men have failed in a great degree to effect. It has been said that " a continual dropping will wear away a stone." Upon this principle, I shall venture to drop a word or two in relation to a subject that requires "line upon line, precept upon precept, here a little and there a little," that some of the obstacles which have hitherto interposed to obstruct advancement " in elevating the standard of medical education," may be gradu- ally worn away and overcome. It has been charged that "the medical colleges have not re- sponded as generally or as cordially to the recommendation of the 8 Association, as was desirable."1 In short, they have been charged with being inimical to changes-to advancement, to improvement in medical education. To a certain extent this may be true, but that all of our medical colleges and professors are incorrigibly " old fogyish," I would most respectfully deny. I have been a medical teacher for nearly forty-three years, and the more defects I see in the education of the candidates for profes- sional honor and emolument, the deeper do I feel the necessity of reform and improvement in the rudimental discipline of those who are rushing so fast into the ranks of our profession. A mere glance at the Transactions of this Association, especially at the reports of committees on medical education, must satisfy any one of the necessity of the efforts that have been made to accomplish an object of so much importance to the dignity and honor of our profession, and to the welfare of the public. One of our late Presidents,2 in his address, remarks, "The grand object of our Association, the education of the great body of the medical profession to greater respectability and more extended usefulness, is still far from being adequately accomplished. While much has been done-enough to encourage us to more earnest effort-a great deal remains to be done. In this direction, the great want is a more thorough preliminary and professional educa- tion. This is admitted on all hands; but to find and apply the remedy is a task at once difficult and ungracious." For a statement of what has been proposed, and, in some degree, accomplished by the labors of the members of this Association, I beg to refer to what the author3 calls, "A condensed statement of what has been attempted for the advancement of medical education, by the medical conventions of 1846 and 1847, and by the American Medical Association since its organization in 1847, published in the Transactions of the Medical Society of the State of New York, in 1860." The author says: " The object I have in view is to bring the labor thus bestowed into a small compass, that at a bird's-eye view, as it were, it may be seen what has been done." I hardly need say that this object has been ably and faithfully carried out. In this "condensed statement" there will be found a great variety of propositions to elevate the standard of medical education. These 1 Dr. C. C. Cox. 2 Dr. Harvey Lindsley. 3 Dr. Thomas W. Blatchford. 9 relate to preliminary education-to the lengthening of the term of medical studies-to the lengthening of the lecture terms-to an in- crease of the number of terms-to a board of examiners separate, distinct, and independent of the professors-to a mixed board-to a more thorough and rigid examination for the degree of Doctor of Medicine-to a second degree-to the age to 'which the student shall attain before commencing the study of medicine, and to many other minor points, too numerous here to be mentioned. It is believed that to aim high for intellectual and honorable attainments, and for position in society, will equally apply to pro- fessional acquirements; and yet is there not danger of grasping at too much? Theory is one thing and practice is another. Let us strive to accomplish that which is practical. One1 demands, as an indispensable prerequisite to enrolment as a student of medicine, " that the party shall be at least seventeen years of age, of good moral character and habits, and that he shall have received a good English, classical, and mathematical education, be able to read and translate the Latin language, and have an elementary knowledge of the Greek, so far as to be able to trace the derivations from it in the English language." Another2 would require " a thorough preliminary education in Latin, mathematics, and physics, as essential prerequisites to the admission of a student into the office of a medical preceptor, or as a matriculant of a respectable medical college." One of my predecessors in office,3 in his address before this Association, boldly asserted, " That the education of physicians has not kept pace with that of theologians, or even lawyers, and our profession has so far lost caste as scarcely to deserve to be ranked among the learned." Now whether this be an exaggeration of the truth or not, is not for me to decide. But inasmuch as the author has been for many years a practical teacher, a man of extended observation, and withal, as we believe, speaking from the honest convictions of his own experience, we are bound to regard it as truthful. The same author, in speaking of the defects of a preliminary education of those who have entered, and are yearly entering, the ranks of our profession, remarks, "I am constrained to say, that even at this late period, the profession abounds in students and 1 Dr. D. M. Reese. • 2 Dr. C. C. Cox. 3 Dr. Henry Miller. 10 practitioners who are radically defective in spelling, grammar, etymology, descriptive geography, and arithmetic." After making this humiliating and lamentable confession, he adds, "For this sad decadence of medical education, either private precep- tors or the professors in our medical colleges, or both, must be judged responsible, for they alone are its guardians." One of my colleagues' of the Albany Medical College, in a "Report of the Committee on Medical Education of the Medical Society of the State of New York," published Feb. 1859, very sim- ply and comprehensively arranges the subject of reform under the three following heads : " First. The necessity of a more thorough preliminary education before entering upon the studies of the profession. "Second. A longer and more thorough (and by that we do not mean merely a more extensive) course at the medical schools. " Third. A more thorough and severe ordeal for the final exa- mination." How these points may be established and carried out, seemed to puzzle my friend about as much as it has those who have previously discussed the same subject. If we cannot agree upon a high amount of preliminary instruc- tion, embracing Latin, Greek, and the higher mathematics, let us insist that the candidates for the study of medicine shall not be justly chargeable with being "radically defective in spelling, grammar, and etymology." Now it seems to us but reasonable and strictly proper, that the preceptor-the physician, and not the professor, into whose office the pupil first enters-should be held responsible for this reasonable demand-a demand altogether prac- ticable. As to this defect in early education I cannot fully agree with my honorable friend,2 who ma<Je the last report to this Association on this subject, who says, "The professors of colleges, who should sustain the relation of faithful custodians to the temple of science, admitting nothing unworthy within its sacred portals, are chiefly deserving of censure." Important as it is that the student should be suitably prepared before entering upon his medical studies, nevertheless it is not all that is required to make an intelligent and safe physician. In proof of this we would cite some illustrations within our own experience, of young men to whom had been given all the advan- 1 Prof. Howard Townsend. 2 Dr. C. C. Cox. 11 tages of an excellent primary education, yet who were entirely deficient in their examination for the degree of doctor of medicine. We know, for example, of some cases, where the candidate for the degree described corrosive sublimate as a preparation of copper, and that three or four grains should be given as the dose. Hydrocyanic acid, to be given in doses of ten grains ; that aconite was a preparation of zinc and must be given in doses of eight or ten grains; and without going into detail of the examination, the whole of which proved extreme ignorance in one of the depart- ments of the profession where one ought to be the strongest before presuming to take charge of a patient; since here he would become the agent, as it were, of Death, instead of being instrumental in restoring health, which is the ultimate object of his profession. We cheerfully allow, that to accomplish the second and third points-that of " a longer and more thorough course at the medi- cal schools, and a more thorough and severe ordeal for the final examination," the professors of medical colleges should be held strictly accountable; as we assume that it is through the medical colleges that almost all candidates for the practice of physic and surgery find access to our ranks. Bearing upon this subject, however, I beg leave to state one re- markable fact-and that is, that the Boards of Censors of the Medi- cal Society of the State of New York, who have the legal right to examine and to give diplomas to candidates for the practice of physic and surgery, in ten years previous to 1862, licensed only four candidates, and that in two years, 1862 and 1863, the same boards examined and licensed nineteen candidates. Now the State law only requires that the candidate for a State license shall present a certificate of three years of medical study with some licensed physician, and to sustain such an examination as the censors may see fit to impose. It is claimed that the exigencies of the war have called for a great increase of medical men. Be it so-but can that be any excuse for thrusting incompetent men into that important service? I do not say that these licentiates had not attended two, or even one full course of lectures at any of our medical colleges-that they never used a knife on the dead body for the study of practical anatomy-that they never saw the inside of a hospital, nor that all or any one of them had been rejected as candidates for gradu- ation at some respectable medical college. But that there was some reason why these nineteen licentiates did not enter the "tern- 12 pie of medical science, through the sacred portals of some medical college," there can be but little doubt. If more instruction can be imparted in a given time at our medical colleges, in attendance on lectures and recitations, in hospital practice and college cliniques, than in the office of a private physician, let us demand more of this kind of instruction. Let us attempt to make such an advance as can be accomplished. The gentleman1 to whom we have just referred, in his report says: " There should be not less than three courses of lectures of six months each in duration." My colleague, in his report remarks: "Instead of courses of lectures continuing only four or five months, they should, as in literary and scientific colleges generally, be continued for ten months of the year, or perhaps we may better express it by saying that they should be continued throughout the year, excepting some eight for ten weeks or vacation." If three six months' courses of lectures-or the continuance of lectures " throughout the year" with the exception of a few weeks of vacation-were deemed advantageous to students, I think it would be asking or demanding too much at once, at least in the present state of medical feeling-an impracticability. Our observation has been, after many years of experience (and I believe it will coincide with that of other teachers), that medical students always learn faster, and retain what they learn longer, in the first half of the time of a four months' course of lectures. If they become weary, careless, and inattentive, if not mischievous and unruly, before the close of a four months' course,,might they not become restless and unmanageable before the close of a six months' course? I am, therefore, an advocate for demanding for graduation three full four months courses. Let not these courses be curtailed at either end a single week; let no partial course or extra attention to any one department be received in lieu of full courses. If all the colleges will agree on this requirement, and faithfully adhere to it, we can see no reason why it may not be accomplished. Upon the third and last point I agree with my colleague: "That the final examination for the degree should be one of severity; thoroughness, and impartiality." We do not intend to impugn the motives of professors in voting ' Dr. C. C. Cox. 13 to pass incompetent men, and to confer upon them the highest medical honor. It has been said of one candidate that "he has been in practice several years, and can continue to do so, in our State, without even a license-on the whole, he will be a safe practitioner;" a second "has spent all his substance to get along thus far-is too poor to live longer without earning something in his profession; he has no money, nor friends to whom he can go for aid;" and still the excuse for another stupid fellow is, "that he will never learn any more by longer study, or by attending any more lectures; in short, the longer he is kept back, the less he will know." These and similar apologies should have no influence on the judgment and decision of the high-minded and conscientious professor. Such unworthy specimens are sure to bring dishonor upon the institution from which they graduate, and disgrace upon the whole profession. Let the standard of requirements have a broad margin; and by no sympathy or false philosophy permit any imperfectly prepared candidate to pass a definite and fixed boundary line. If the farmer, in gathering and preparing his potatoes for the market, should insert among the marketable ones, only two quarts in a bushel of the refuse (the small potatoes), and thus spoil the sale of the whole, we should all say that it was a piece of bad management, poor philosophy, and worsP economy. There must be a limit somewhere to the extent of our lenity; and the crushing effect, if it may be thus called, had better fall on one or two, or even half a dozen, rather than that a large com- munity should suffer, and that the whole medical profession should be disgraced. It is the "small potato doctors"-those who do not succeed in the regular practice-that are most apt to apostatize- to depart from the regular faith, and become "small pill," as well as " small potato doctors." These suggestions I have thought proper to offer, with the sincere desire that some good may grow out of them. I would farther suggest that the annual meetings of the "Teachers' Convention" be renewed; and that all the medical colleges in the United States be earnestly and cordially invited to enter with zeal and decided activity upon the adoption of such measures as may be best calcu- lated to effect the object aimed at-the elevation of the standard of medical education. If the first effort of holding a " Teachers' Convention" in 1859 was so far successful as to have thirteen States and twenty-one 14 colleges represented, we see no valid reason why, by perseverance, all the States and medical colleges may not, in time, be induced to engage in the furtherance of this desirable reform. Gentlemen, I have already occupied more time than I had assigned to myself, and fear I have wearied your patience. And now, during this brief period of my services, let me crave the same kind indulgence and support which it was my pleasure to enjoy on a former occasion, until I shall have the delightful privilege of handing over to my successor the insignia of an office of so much honor and responsibility.