Introductory lecture, READ AT THE COMMENCEMENT OF THE COURSE, Vf<*' BY S. HENRY DICKSON, M. D. h'< Professor of the Institutes and Practice of Medicine IN THE MED. COL. OF THE STATE OF SOUTH-CABOLINA. MONDAY, NOVEMBER 9th, 1846. PUBLISHED BY THE CLASS. CHARLESTON: WALKER & BURKE, PRINTERS, 87 EAST-BAY, 1846. INTRODUCTORY LECTURE. I bid you once more welcome—gentlemen! Once more congratulate myself upon the return of the period of our meeting, and the resumption of my responsible and inte- resting duties. With unaffected anxiety, yet with exci- ting and hopeful ambition, I again devote myself to the task of professional instruction, and set forth to lead you onward in the steep but not unpleasant paths which conduct to knowledge and usefulness. We live in a day of active movement. All art and every science labour for prompt and definite results Men are enthusiastically bent on making progress; and the recent successes attained in their eager efforts, are almost miraculous. Within the last half century steam has been tamed and harnessed to the car, and chained like a galley-slave to the oar; and the thunder-cloud not only disarmed of its dreaded bolt, but compelled to become our messenger and newsman Time and space are thus literally annihilated, and the powers of mind rendered completely triumphant over the obstacles pre- sented by grosser matter. The glowing sunbeam is arrested in its rapid flight; and shadows—proverbially transient—disposed into living pictures, images of inani- mate nature and of the human face divine,—fixed and rendered more permanent than life and nature them- selves. The decay of frail mortality is prevented, and the delicate structures of which our bodies are consti- tuted, by some marvellous process of petrifaction rever- 4 sing the fable of Pygmalion, hardened and converted into stone. Nor is it only in the physical world that such trophies as these are gathered. Right or wrong—for weal or for woe—the desire of improvement runs hastily forward into the experiment of change and substitution, and reform is the universal watchword of the masses, however divided or bound together. New laws, new governments, new constitutions are tried; new theories of instruction, of subsistence, and of punishment, are becoming prevalent; and in this ferment the conservative is confounded with the stationary laggard, and like him despised and trampled on. When all is thus in motion around us, it is difficult, if not impossible, that we should stand still if we were inclined; and our profession, as you know, has been from the earliest times given to the desire of change and the hope of improvement. Medical reform is the order of the day; and those who know best the condition of things in medicine, whether considered as an art or a science, are most thoroughly convinced of the reason- ableness of the demand, and the call for prompt com- pliance with it—the inevitable necessity of vigorous and earnest action. This will appear clearly whether we regard our actual position internally and absolutely, or externally in our social relations to the community, and comparatively with other departments of learning. No one can entertain a higher sentiment of veneration for the time-honoured calling of the physician than I. In sacred and profane records, we find this reverence to have existed from the earliest ages. "He shall receive honour from the King," says the wise son of Sirach, "and in the sight of great men he shall be in admiration." Homer speaks of Machaon—as "Worth whole armies to the Commonweal." 5 In the unchanging East, these feelings remain the same at the present day, and are well expressed by Southey, in a fine passage of Thalaba— "All men hold in honour "The skilful Leech. From land to land he goes "Safe in his privilege; the sword of war "Spares him; kings welcome him with costly gifts; "And he who late had from the couch of pain "Lifted a languid look to him for aid "Beholds him with glad eyes, and blesses him "In his first thankful prayer " WTe regret to observe that in modern times and among civilized nations, (so called) these sentiments have become much modified, this high regard has suffered much abatement. Philosophers have gravely doubted both the certainty and the value of our attainments; poetasters utter dojgerel rhymes against us; dramatists and would be wits habitually jeer and taunt us; and lawgivers, in this new world, seem bent upon taking from us all protection, and even appear ready to deny us the courtesy of a formal recognition. The practice of medicine has been defined or described in contemptuous phrases in the two most extensively used of modern languages, and by great authorities in both. Voltaire speaks of it as "the business of pouring drugs of which we know little into a body of which we know less;" and the sour English dogmatist, Dr. Samuel Johnson, calumniates it as "a melancholy attendance on misery; a mean submission to peevishness; and a perpetual inter- ruption to pleasure" Deeply indebted, as he was, personally, to physicians and their art, he should have been struck with the perverse application of his own epithets, and been gratefully ready to recognize an "attendance on misery," rendered cheerful by benevolence and hope;, a "submission to peevishness" induced by kindness and pity, and thus rendered magnanimous, not "mean;"—and a noble self-sacrifice in bearing with a life 6 whose "pleasures are perpetually interrupted" by the recurrence of laborious duties. The ignorance of physicians—their want rather of certain kinds of knowledge, pithily expressed in Voltaire's sentence of condemnation, is a favorite topic with certain writers. But of what are they ignorant? Their profes- sion is among the learned ones, how happens it that ignorance is specially predicable of its cultivators ! Medi- cine is styled by some "an inscrutable mystery;" our differences of opinion are sneering'y dwelt on. Whewell ailirms that no single physiological principle has been established. The doctrines of Pathology are declared to be ever varying and unsettled. The very facts of Therapeutics are asserted to he, all ot them, disputable and disputed. Let us first observe, in reference to this suhject, that if physicians are ignorant of Physiology, Pathology and Therapeutics, this deficiency is rendered more remark- able by their universal and acknowledged attainments in all other departments of literature and science—all other branches of human knowledge. In what field have they not distinguished themselves by their industry capacity and success! What age is not made illustrious by their names! What country does not regard them as among her most enlightened citizens as well as her best benefactors! The first President of the College of Physi- cians in London, Dr. Linacre, was the first teacher of Greek in the world-renowned school of Oxford, and founded lectures both there and at her sister University of Cambridge;—and the second Greek Professor at Oxfjrd was also a physician—Dr. John Clements. Of Dr. Linacre, the great Erasmus spoke in the highest terms, calling him "Poluteknotaton—Grsecum, Latinum, Mathematicum, Philosophicum, Medicum." Writing of 7 physicians, he says, that he "had many good friends among them," and adds that "they have usually been such to men of letters." His biographer, the learned Dr. Jortin, remarks in passing—"If Erasmus had lived " in these times he would have found it needless to exhort " the gent'emen of that profession to the study of the " languages and of polite literature, in which so many of "them have distinguished themselves." It would be easy to bring forward an array of bright names, living and dead, to show that we still deserve the same eulogy; that we are entitled to claim the same regard as in the times of Jortin and of Erasmus. It was one of us that founded the "Royal Society" of England: one of us, who, in the bold attempt to lay open a new world of knowledge, even in his failure, enlarged indefinitely the bounds of metaphysical science by the aid of the facts and observations of Phrenology. If the "proper study of mankind is man"—if his mental improvement, general progress, and the suggestion of remedies for the evils which afflict our race form the loftiest objects of interest, who shall be preferred before our South wood Smith, Chadwrek, Conolly, Farr and Prilchard, on the other side of the Atlantic; and on this, our Morton, our Howe, our Woodward, Bell and Brigham. Now, would it not be strange, indeed, if these men, and such as these, their brethren—a long list of whom I might have made out, selecting those mentioned, not from any invidious favoritism, but merely as familiar to my thoughts, and occurring to my memory at the moment of writing—would it not be strange, if such men, thus distinguished by ability and attainment, in every other field of research, should have effected nothing in that very department of knowledge to which they have devo- ted themselves with intense ardour and enthusiasm? 8 The assertion is preposterously absurd—ridiculously false. In Anatomy, we have explored the "fearful" recesses of the "wonderful" frame of animals and man; with the microscope and the scalpel, we have unravelled the exquisitely-woven tissues—traced the nerves—de- veloped the glandular parenchyma, and made out the figures of the primary cells and the fluid globules. In Physiology, we have ascertained power from organiza- tion, and inferred function from structure; determined modes of action, and from effects deduced their causes. In Pathology, we have in numerous examples pointed out the relation of disease to its sources; warned against dangerous exposure, and laid down rules for continuous progress in observation and enquiry. In Therapeutics, we have prepared and made available many antidotes to the most deleterious poisons; institu- ted and applied with habitual, if not uniform success, many remedial measures in painful and threatening maladies; and discovered more than one specific, among which, quinine alone has proved of infinitely more value than the long sought agent for transmuting metals into gold—preserving, annually, the lives, and restoring the health of thousands and hundreds of thousands. In Hygiene, the loftiest of our beneficent offices, we have suggested many modes of prevention—pointed out effectual means of disinfection—neutralized many agents of evil; in the application of vaccine, we have offered to the world a triple shield of defence against one of the most horrible and destructive forms of pestilence. We have contributed our full share in the better manage- ment of the physical education of the young; in the enhancement of all the enjoyments of life, and in extend- ing its average duration. 9 But I will dwell no longer upon this theme. Self- glorification is apt to be too pleasant an exercise, and should be limited strictly to such occasions as are urged upon us by the necessities of self defence. Let us rather seek to know and remedy our defects and failures, and "forgetting the things which are behind," press forward to nobler attainments and higher and more complete success. Our absolute position is briefly to be described as less unequivocally gratifying than our relative or com- parative of which I have thus spoken. Yet in this we are far from being alone. Who is satisfied with the actual state of civil governments—of the social life of communities? Are there no disputes among Philoso- phers as to the doctrines of science—among Theologians as to religious dogmas—among Legislators as to legal ordinances? Who has the right to throw the first stone at us for our contentions and strifes of opinion? There are two modes in which change may become necessary in received systems; one of which consists in the acces- sion of light—the addition of acquired facts. It is just and fair to account for the endless variety and quick substitution of medical theories and principles as well by reference to this rapid and uninterrupted augmentation of knowledge, as to the inherent uncertainty and obscu- rity of the subject itself—the sources to which they are generally ascribed. In which of the sciences does such accumulation go on more quickly or more continuously? All the several departments of human learning are now rendered tributary to medicine by its illustrious cultiva- tors, who avail themselves eagerly of every discovery in nature and art—every suggestion, physical and moral, and thus press forward to perpetual change and improve- ment. For my part I look upon this luxuriant growth, quick renovation, and incessant presentation of new 3 10 features as'the very best proof of vitality, energy and flourishing vigour. Yet, if this be fully established, it will not militate against the assumption with which 1 set out— that the demand for medical reform—especially in our own country—is reasonable and must be complied with I am prepared now, and have ever been, to maintain that as a body, the physicians of these United States have effected as much in the higher departments of their profession as their brethren any where else. In Hygiene and the Practice proper—both of medicine and sur- gery—the relief of suffering, the restoration of mental intelligence and of bodily health, and the prevention of disease, are as successfully attempted among us as in any other part of the world. But these successes are attained under very obvious disadvantages; some of which are the essential coincidents of our social condition, while others are self-imposed or the con- sequences of a culpable inattention or indifference. These, and particularly the latter, it is our duty to point out clearly as soon as we become aware of them, and remedy, as far as possible, and without delay. Strongly impressed with this duty, certain members of our body have, at different times, held meetings and formed associations for the purposes of mutual improve- ment and reformation. It is to this feeling, in part at least, that we owe the incorporation of Medical Societies in our cities, districts and states; reunions which I hear- tily approve of, and would gladly see established every where. Hence the attempt at a General Convention in Northampton in 1826, and in Philadelphia in 1828—the convention for a National Pharmacopoeia in 1>29, and again in New York in 1830, and in Philadelphia in 1831—and hence has arisen the recent and more general movement consequent immediately upon a call from the 11 Medical Society of the State of New York. A National Medical Convention was held in May last, in New York city, consisting of delegates from a great many portions of the United States. This highly respectable body, during their session, entertained several impressive reso- lutions, and appointed an adjourned meeting for their further consideration, to take place in Philadelphia in Mav 1847 Among these, they advocate the expediency " of a National Medical Association for the protection of " the interests of the profession—for the maintenance of " their honor and respectability—for the advancement of " their knowledge, and the extension of their usefulness." They farther recommend the "adoption of an elevated •'and uniform standard of requirements for the degree " of M. D, by the Medical Schools of the United States, " and of preliminary education and attainments, to be "exacted of students of medicine before they are received " as such, and of the reception by our whole body of the "same code cf Medical Ethics." And lastly, they de- clare the sense of a large majority of the Convention, "that the union of the business of teaching and licensing " in the same hands is wrong in principle and liable to "great abuse in practice;" and suggest the appointment of a Licensing Board in each State, "composed of re- presentatives from its Medical Colleges in fair propor- " tion, and the profession at large." In these views,I fully and unhesitatingly concur; and shall now proceed to offer, in support of them, such ar- guments and illustrations as may be condensed within the admissible limits of the present occasion. I know not how I c in better employ the time allotted me for addressing you at this, our first meeting. Several of you will be soon eligible as members of this great Conven- tion; many, if not most of you, will join, I trust, without 12 delay, the National Association, to which it will give birth before its final dispersion; and all of you are pro- foundly interested in the acceptance and prosecution of measures adapted to elevate the character of the profes- sion to which you belong, and to enable it to effect, more fully, its lofty objects and beneficent purposes. One of the most important of the suggestions offered us by the Convention, is the elevation of the standard of preliminary education, previous to the admission of stu- dents of medicine. Great care should be taken to regard this matter in all its extensive relations before any rule be laid down. We must not make impossible demands upon the youth of our country, nor forget for a moment, the immense differences that exist, not only between ourselves and our brethren in the older communities of Europe, but also among the several sections of our own wide and rapidly spreading country. In towns and cities, the standard of early education is every where higher than in the dispersed populations of the interior and agricultural districts; in the Northern and Middle States than in the Southern and Western. To exact from the ambitious and diligent youth of the latter then, the same formal acquirements, would be unfair until they have been provided with similar opportunities; and yet we cannot prohibit them from entering the arena, nor give any artificial advantages to their rivals, which shall result in driving them from the field. We know that notwithstanding the scarcity of schools in these regions, and their confessed inferiority in general, our pupils grow up into adroit surgeons and sagacious physicians. Yet, however successfully they may struggle against the diffi- culties that press upon them,—however high they may rise in usefulness and honor, in spite of these difficulties, nothing can be more certain than that their success 13 wonld be more complete, they would attain greater honor and usefulness under better auspices and in more favo- rable circumstances. We must aim to hit the just medium; and while we give all due weight to early dis- cipline and systematic training, we must offer every avail- able inducement to the exertion of peculiar diligence and perseverance, and take care not to discourage true talent and native energy, however repressed by adverse con- tingencies. With reference to the point next to be discussed, I agree far more unreservedly with my brethren of the Convention. I have pleaded for some indulgence in the reception of students at the commencement of their course; I would unite in the most extensive and strin- gent requisitions for the ordeal at its termination. I do this because I am satisfied that if a young man enters the office of his preceptor at a proper age, devotes a sufficient period to his course of study, and exerts, during that period, a due degree of diligence, he may easily do all that ought to be demanded of him. But he who unadvisedly commences too late the study of the most extensive of all the departments of human knowledge; runs hastily over the condensed and aphoristic instruc- tions of its meagre list of text books and manuals ; listens drowsily, carelessly and irregularly to a brief and com- pendious series of oral or written essays upon some of its numerous divisions; makes a few hurried dissections; and witnesses, at greater or less distance, an occasional operation ; must indeed possess genius of a high order, or caution and sagacity far beyond the average, if he enters life at all fitted for its weighty duties. It is a grievous charge against the profession in these United States that its highest nominal rank is attainable at such a low rate of scientific acquirement, and with so 14 .little expenditure of time and labor. One cannot help being struck with the immense difference in this regard between us and our transatlantic brethren. In France, the candidate must attend four courses of lectures at least, upon all the various branches of medical science, and undergo three examinations, some of the answers at which must be written extemporaneously, and in full detail. The "preliminary literary guarantees" demanded of pupils are a Bachelor's degree in Arts, and a Bache- lor's degree in Sciences. They presuppose a classical and scientific education of ten years' duration. Yet the Medical Congress which lately met in Paris, a most august and imposing body, while they express their approbation of these preliminary guarantees as "suffi- cient but not too onerous," recommend as expedient that the duration of medical studies now occupying a period of four years be prolonged to five; that an exami- nation be exacted at the end of each year; and that all students be obliged to serve for at least a year as dressers in a hospital. In England, the degree of Doctor of Med'cine is not to be reached with less than eight years of study. At the University of London, the most liberal of the Eng- lish schools, the student cannot even enter without an examination; he cannot be matriculated unless he " shows a competent knowledge of the classics, including " the English language, history and geography, mathe- " matics and natural philosophy or chemistry." Before graduating as Doctor, he must have past two examina- tions for the Bachelor's degree, and "a third, which is final;" exhibiting his attainments not only in "physi- "ology, general pathology, general therapeutics, hygiene, "surgery, practice of physic, midwifery and forensic u medicine, or medical jurisprudence; but also in logic, 15 " and intellectual and moral philosophy." The number of persons admitted last year to the Doctorate of Medi- cine in England, was not more than 77 ; in our own country it amounted to fully 1000! Within the last three years, the whole number of those licensed to practise as physicians, surgeons and apothecaries in England and Wales, is stated by the Medical Gazette at 2,721, being an annual average of 907. It is impossible to ascertain how many among us procure or assume the license to practice, which is indeed almost absolutely without restraint or limit. It is, I fear, entirely too late, even if it were not out of place here to discuss the question of the propriety or impropriety, the good or evil of this unrestricted system. The movement party are every where in the ascendant, the conservative principle almost extinguished ; and we are going on to experiment freely upon the possibility of an existence untrammelled by any of the forms, which, in the Old World, are associated with recollections of inequality aud oppression. In our vast republic, men shall hereafter preach, litigate, and prescribe ad libitum; and the monopoly of skill, of preparation, and of dili- gence, no longer lie heavy on the bosom of the community. It is possible that these tendencies shall be arrested— but the struggle is almost hopeless. On this downward road, as on the path to the den of Cacus, nulla vestigia retrorsum. In the meanwhile it behoves the profession, totally unprotected as it is likely to be, by any legislative countenance, to consider how it shall preserve itself from utter prostration and annihilation. We cannot require, as I have admitted, any high standard of prepa- ratory education—the "preliminary literary guarantees" of the French system—but to compensate for this defect, we are bound to insist on a long-protracted and exten- 16 sive course of technical studies. If human life and human health be worth consideration at all, and if pro- fessional ignorance can injure, and professional expert- ness can benefit mankind—questions which I cannot stoop even to entertain in this place, but shall assume the affirmative to be as clearly true as any proposition that can be submitted in language—then we should do all that we possibly can do to make the acquisition of knowledge certain, easy, full, nay, unavoidable. And how else can we effect this than by multiplying the opportunities presented to the student, and keeping him long in contact with the sources of information. Our systems must be accommodated to the wants and requirements of the average mind—the ordinary capa- city. Talents and assiduity run rapidly forward and promptly overcome whatever difficulties lie in their way; but we must legislate also for dulness and indo- lence. These must be aided and stimulated. "Repeti- tion—repetition," said the learned Wyttembach, "is to the scholar what action, action, action is to the orator;" and by frequent repetition, even the dullest will be instructed, and the slowest urged onward. Besides this, it never should be forgotten that whatever is cau_>ht up hurriedly is apt to be slightly impressed on the un- derstanding and the memory; while acquisitions, more deliberately made, fix themselves with greater perma- nence, and stand out ever after with clearer distinctness in the mind. I have already drawn a sketch of our American mode of study—text books read exclusively or almost exclusively, cursorily, hastily; two half courses or one brief course and a half of lectures attended—lis- tened to perhaps; a single dead body dissected under the eye of a Demonstrator, perhaps an arm only or a leg; a few surgical operations witnessed, such as may accident- 17 ally present themselves within the six months spent at the colleges; a few patients seen in the wards of a hospi- tal at intervals of days, or it may be weeks. Our schools generally require three years of such study; but how sel- dom is even this rule fully complied with. The standard is so low, that any common industry may overleap it in half the time. We demand the legal age of maturity to be attained before the reverend Doctorate shall be reach- ed—but our transatlantic youth, like the country which gives them birth, are of so quick and precocious growth, that they are universally ripened into grave manhood at or before twenty, if the family Bible and the parish regis- ter are to be trusted. There are many honorable exceptions I am aware—but I appeal to those who hear me, whether I colour or exaggerate in the picture I have thus drawn. It is in reference to this matter, principally perhaps, that a National Convention of Physicians, and the influ- ence which it is capable of exerting, will be available. The relaxation of definite rules—the depreciation of the requirements for collegiate honours, are clearly owing to the colleges themselves, and result from a vehement com- petition—growing every day more reckless on account of the multiplication of schools. Unless some concert of action be agreed upon, the Faculties will continue to dread the suicidal effect of any special stringency or pre- cision, in repelling students and reducing the numbers of their classes. With this concert of action, however, much may be gained; for even if some of the schools prove recusant, their refusal to be bound by a general law will serve to divide the colleges themselves into two grades—one of higher and one of lower requisitions; and thus we shall establish a precise line of distinction between the higher and lower order of attainments. The 3 18 title—-per se—I need not tell you is already worth nothing It is either assumed at pleasure or forced upon the tyro and the quack ; and what I am obliged to share with the ignorant purchaser of a "patent right," or the concoctor of secret nostrums—the mere seller of drugs, or the unprincipled pow-wow conjuror and mesmerist, I not only cease to value, but positively contemn. It has been proposed as a remedy for this state of things, confessedly so unhappy and injurious, that the collegiate h ,nors of medicine should be dispensed, not by the teachers or professors of the several schools, but by trustees, committees or other bodies, organized for the purpose of examining candidates and conferring the me- rited titles. This proposal would be reasonable enough if the graduating power was necessarily the licensing power, and if a diploma gave a monopoly or privilege in practice. But this neither is, nor perhaps ought to be the fact. Those who are fit to be entrusted with the high office of instruction, cannot surely be unqualified to judge of the attainments of their pupils; but while their competency has been admitted, it has been sug- gested that their judgment is likely to be warped by partialities and prepossessions of various character. The evil thus supposed to arise may, however, be abundantly obviated by leaving the scholastic reputation of the col- leges to their own care, while the community is guarded by proper regulations of which I shall speak hereafter— from the intrusion of unfit practitioners. When a fair standard of professional requisition has been agreed on and established, the position of any school, among its rivals, may be readily known ; in the first place by its adhesion to the common body of rules; and in the second, by the general character of its gra- duates. There may be some advantage in the publicity 19 of examinations, recommended by some writers, and practised, I believe, at Geneva, N. Y.; but there are very weighty objections against it. Those experienced in examinations are aware that they constitute very imper- fect and often deceptive tests of the attainments and standing of the candidates: merit—scientific merit, at least, is frequently connected with that species of timi- dity which confuses the memory and enchains the tongue. Young men differ widely as to the readiness and precision of their habitual language, and this differ- i no? ence is much increased by education. Self-possession and promptness in reply, are not necessarily associated with self-possession and promptness in action; and he who would be readiest in taking up a wounded artery; or prescribing efficiently for a violent attack of menacing disease, may be uncertain, slow and fearful in his an- swers to the inquiry how these things should be done. I appeal to the experience of all examiners whether they do not often and involuntarily—nay, inevitably form opinions of candidates entirely different from or even opposite to those which they would have obtained from the mere examinations, however skilfully, impartially, cautiously, and patiently conducted. We who instruct you, must necessarily acquire some knowledge of you j and of your training an I qualities. WTe cannot help inferring from our observation, your attention, your dili- gence, your habits of inquiry. We find some of you gifted with quickness of apprehension, who are slow of speech, and otheri voluble and fluent, who are dull to learn and uncertain in judgment. By meeting you here and elsewhere, and conversing with each other of youj for von have become and will continue to be for some months, objects of paramount interest to us; we must become more or less acquainted with you, perhaps even 20 familiar. We can and do judge fairly of you; and the experience of a quarter of a century enables me to affirm that we rarely fail to judge correctly. The character which a student carries with him hence, is almost inva- riably that which the world afterwards confirms and fixes upon him. Now, if the examination be only one of a series of tests and observations, as it ought to be, to which the student is submitted before he attains the honors of the profession, it is evident that the concen- tration of large masses of young men in such numbersj that they cannot be personally known to their exami- ners, is an evil rather than a benefit, and will reconcile us to the multiplication of colleges as within a certain limit, very desirable. The good effect of the contingen- cies of which I have just spoken, would be done away by the publicity of the examinations. They would probably be attended chiefly, if not exclusively, by friends or enemies of the candidates, whose influence would only avail to disturb and confuse the proceed- ings, and give rise to future controversy and discontent. If such attendance were made an official duty, tran- siently devolving upon individuals changed from time to time, none could gain that experience necessary to its proper and faithful and efficient performance. If it were made an official duty, belonging to a permanent body, the result would ultimately be a mere substitution of one set of examiners by another quite as partial and sus- ceptible of being moved unfairly, without the opportunity of forming as competent a judgment of the merits to be enquired into; for these, by the very nature of the case, are referable to character and scholastic qualification. The mortification of failure is already so unduly and unreasonably great, so strongly disproportioned to the honor of success, that any change which shall tend to 21 increase it is unadvisable. I prefer to offer inducement upon inducement, and heap facility upon facility, to accumulate means and appliances for study and instruc- tion, and provide an array of premiums and distinctions to prevail upon the student to exert himself, rather than leave him to indolence or permit him to hurry himself forward—and then at the end of his curriculum raise barriers which it will be difficult for him to get over. This would be both impolitic and unjust. I have just spoken of prem.ums and distinctions, and must not omit to say, that with regard to these I would follow a very different plan. While I would intrust to the several faculties, respectively, the care of the reputa- tion of their colleges in the distribution of the ordinary titles, I would aid them in awarding special honours to such candidates as contend for them, both by the publi- city of the contest and the appointment of special judges. The claim presented here is of a nature to be consider ed and passed upon by any competent persons; and their removal from all immediate connection with the candi- dates is the best guarantee for their impartiality. I am disposed to advocate the institution of some such ordeal as the French Concours in the selection of Professors to fill the chairs in our universities, and find the only objec- tion—a fatal one at present, I grant—in the want of an umpire of full and adequate authority to decide among the claimants; so also, and without being embarrassed by any similar objection, would I desire to see a fair field for public exhibition of special qualification and attain- ments offered to every candidate who might aspire to such distinction. I would here notice a singular feeling—an unfounded one as I think—a prejudice—often expressed by physi- 22 cians in reference to the result of examinations of classes in our medical schools. It is often imputed as a fault, nay, a fault deserving severe censure, that they are too lenient—that too large a proportion of the classes succeed—and that too few are "rejected." Nothing can be more unjust or groundless than these views. In our academical institutions, the rule is, that the classes shall graduate ; the exceptions are comparatively of small number. Why should it be otherwise with us? If tutors and professors have done their duty faithfully, those who have gone through the prescribed course ought to be fairly prepared lor a certi- ficate to that effect; and that is all the value—the true value of a diploma. The real cause of complaint would be and is, that the standard is tjo low—not that too many had come up to it. No one denies or doubts that it is too low in our country every where—far foo low ; and among others I have professed my anxious desire to elevate it, and place the American physician on a level with his transatlantic brethren; but until something is done with this purpose, I will say that the college must be indeed ill provided with teachers and means of instruc- tion—or exceedingly unfortunate, whose Faculty are at present often under the necessity, the wretched necessity of rejecting any candidate who has fully complied with their requisitions. Such cases, i fear, will occasionally occur to all of us; but instead of feeling it to be a matter of regret or apology that they should seldom offer them- selves in the institution to which 1 have the honor to belong, I am, on the other hand, proud to say, that our commencements are frequently in the old phrase "Maiden Sessions," in which we enjoy the comfort of carrying through a series of examinations, which, if not altogether satisfactory, yet, on the whole, present no reason for 23 inflicting, on any one of our pupils, the intolerable pang— tru1 indelible stigma of a rejection. This, we are indeed always anxious to avoid. It is our studied policy to prevent, if possible, the application of any candidate, of whose qualifications we entertain, previously, any serious doubt: and as I have said already, we cannot help know- ing, with probable accuracy, the actual standing of all under our care.* It may now be asked, and it is the most difficult ques- tion to be discussed by the National Convention—what "uniform and elevated standard of requirements for the degree of M 1). shall be adopted by the Medical Schools of the United States?'' I answer that we must be direct- ed somewhat in the formation of a rule by reference to the preliminary education of the pupils. Those destitute of a liberal foundation, in classical studies, for the pro- fessional, scientific and technical attainments indispen- sably to be exacted, should be required to pass* five years at least, under the care and instruction of some estab- lished practitioner; and to attend three courses of chemical and anatomical lectures, dissecting, personally. *What proportion each college might separately show of rejected candidates, would be difficult to ascertain under the present system of attempted secrecy, although it is a topic of ceaseless, earnest and interested inquiry among medical students every where. The number of young men engaged in attending lectures last year in the United States, was computed at 3675, (St. Louis Journal,) of whom about 1000 (one in 3§ nearly) received the degree of M. D. On looking over "the Statistics of Medical Institutions of the United States," collated from the published catalogues I have found this to be a pretty fair statement of the proportion in each institu- tion, the large presenting a somewhat greater relative number than the smaller schools, for the obvious reason, that they are more apt to L e resorted to by those, who, at the conclusion of their course of study, are altogether free to choose for the mere name of their diploma; but the difference is so slight as to be merely fractional. We have some facts in the London Medical Gazette, March 1846, relevant and of instructive purport. During the three years 1842-3-4, the Royal College of Physicians examined 161 candidates and granted 160 licenses. The University of Cambridge granted 10 diplomas, and 9 licenses : Oxford gave diplomas to all who applied, (>', and licensed 7 out of 8. London University, at its first examina- tion, rejected 36 per cent.; at its second, only 10 per cent. The Royal College of Surgeons, which is much complained of as passing unfit persons, examined 17 76 candidates, and granted 1576 diplomas. 24 at least two entire subjects ; and two complete courses on all the other branches taught in the schools. By the word complete here, I mean to define actual attendance throughout, which shall be proved (as in Paris) by fre- quent inscriptions on registers kept for the purpose ; not the implied attendance now customary in our country, when a student may "take out his tickets" "and go through the whole business of the session by proxy; seeing the Lions" of our cities—partaking of all their amusements—and visiting all their places of resort, whether creditable or discreditable, whether by day or by night—their theatres, circusses, race courses, night cellars and gambling houses. The academical degree of Bachelor of Arts from any established university, should carry with it the privilege of abbreviating the course to three years study in an office, and two full series of lectures, with dissections. If the student have not enjoyed the advantage of a col- legiate education, he may be allowed a similar privilege on producing a proper certificate from some competent and well known classical professor or teacher, of his having attained such literary proficiency as would enti- tle him to a degree in college. We do not consider an apprenticeship of seven years too long for the acquirement of a mechanical art: Jive are rot more than sufficient surely for making ourselves acquainted with the divine art of healing; they will scarcely suffice, indeed, for the acquisition of its mere rudiments. After graduating at Yale College, I spent that period in the office of a most laborious and distin- guished physician, and would gladly have extended it still farther, but for the res angusta domi, which forced me to enter into active life and provide for myself. It has always appeared strange to me that our Medical 25 Schools—in this particular, unlike and inferior to our academical institutions—have demanded from their classes no course of reading. Close familiarity with good books, and an intimate acquaintance with their contents, constitute perhaps the best test by which we shall separate the quack or impostor, the mere empiric and the unimproving routine practitioner from the truly scientific physician, deserving of the sacred name. If you do not acquire, early in life, a taste for literary pur- suits, a fondness for extensive reading, depend upon it you will make little or no progress; you will learn little, if any thing valuable yourselves, and will pass through life without communicating any thing valuable to others, or adding one useful item to the general stock of know- ledge. The student who confines himself within the narrow circle of his text books, is destined to live the life of a drudge, and to pass from life without leaving behind him one permanent trace or footmark. The Convention declare their conviction that " the 11 union of the business of teaching and licensing in the " same hands, is wrong in principle, and liable to great " abuse in practice." " As a correction of this abuse, they "propose the appointment of a Licensing Board in " each State, composed of representatives from its Medical " Colleges in fair proportion, and from the profession at " large." The general views thus briefly laid down are substantially correct, and commend themselves to phy- sicians every where, and to the public at large; but they comprise numerous difficulties as to details at every step. In the several states of this union the laws have varied greatly in regard to the license to practice physic. Before the year 1817, South-Carolina knew no restriction whatever; in that year, a law was passed creating two Licensing Boards—one in Columbia and the other in 4 26 Charleston—our Medical Society The erection of the Medical Society into a body of Trustees of a Medical School in 1823, brought about here the very state of things denounced by the Convention. I am not aware, however, that, any practical evil resulted from this union, although it is evident there was much opening for abuse. When a second college—the present—was chartered in 1832, the right to license was conferred upon it also,— and from subsequent changes, it has resulted that this is the only Licensing Board in the State. Our diploma is, in itself, a license, and it is made the duty of our Trus- tees and Faculty to institute an examination into the competency of all such applicants for a license as may present themselves. This apparent privilege is a real burden and a very embarrassing one. Not only is the seeming benefit shared in fact with the patent right which opens the door to every the most ignorant pretender and mountebank; but our diploma, with its pretty seal, its fine motto, and its learned and high-sounding phrases— the insignia of the highest professional rank is thus brought practically into competition and contrast with the mere certificate of license; the latter being obtainable by a brief exhibition of retentive memory—the possible result simply of the well known process of "grinding" or "cramming," as it is called in the British Universities; the former being the ultimate termination of a definite and protracted course of study and mental training. I say nothing of the extreme difference in the cost of the two documents thus perfectly equal in the eye of our wise law—(Coke's "Perfection of Human Reason.") This is an absurd condition of things which cannot and ought not to continue to exist; but the remedy for the evil is unfortunately not in our own hands. We must endeavor to enlighten the community as to their true and 27 pressing interest in this matter; and to convince them that infinite injury must, in the end, accrue to them from their neglect and indifference on the subject. It ought to be regarded as the chief and most funda- mental element in the discussion of the high political topic of municipal Hygiene. In order to enjoy an ele- vated degree of public health, surely one of the predomi- nant considerations in every State, city or community, it is absolutely necessary to set apart a class of well edu- cated practitioners of medicine. Allow for a moment the truth of the proposition—too absurd for comment, but not too absurd to be believed and acted upon by thousands of civilized and instructed men—allow for a moment that actual disease may be cured by the will of a gifted disciple of Mesmer, or by a peculiar magnetic influence emanating from the body of such an one, or by means revealed to a clairvoyant subject in whatever form of prophetic or miraculous inspiration,—or by the uni- versal use of cold water, or the universal application of wet sheets,—or the unlimited administration of whatever familiar drugs or secret nostrums in doses infinitely large or infinitesimally small, secured by patent or benevo- lently made free to all mankind; yet, no one can doubt that a large extent of varied knowledge, an immense amount of learning, a wide expanse of reading, and con- stant inquiry and research are necessary to prepare any one, however wise and sagacious, or inscrutably endowed with mystic powers, for the management of that depart- ment of political economy which looks to the prevention of disease by the removal, avoidance, or counteraction of its causes ; the noblest office this of the learned and experienced physician. Good legal institutions can only be derived from learned and experienced lawyers, and pure and undefiled religion, kept alive only by a body of 28 learned and refined clergy. It is not enough that this matter should be left as it now is, merely to free com- petition and social patronage. In all other professions besides ours, the absolute necessity for protracted, care- ful and diligent training, is universally acknowledged. To every mechanical trade, an apprenticeship must be served; book-keeping does not come by inspiration; a formal examination, ordered by the Judge from the bench, and conducted by grave associates of the long robe, must precede admission to the bar; a pilot cannot attain without serious labour and assiduity, a regular branch; an engineer must rise by accumulating proofs of theoretical qualification and practical competency; the pulpit of every sect is guarded by custom, conven- tional arrangement and positive regulation. In compen- sation for these restraints, carefully defined by ordinance or universally recognized, society, bylaw or by customs having all the force of law, confers on those who com- ply with the conditions thus imposed, certain privileges of specific value and established importance. An intru- der is not permitted to deliver his drowsy common-pla- ces in the church; may not annoy his Honor in Court with unskilful and irrelevant pleadings; or blow up a steam-boat, or locomotive, or run an unlucky vessel on a bar: these immunities are reserved for the formally initi- ated. But neither by law nor custom among us is any one prohibited or prevented from undertaking "to min- " ister to the mind diseased," or the body imbecile, or in pain, or threatened with dissolution. uHic patet inge- nus campus." this field is open to all adventurers with- out restraint of time, or teaching, or character; and the result is as obvious in fact, as it was easily and clearly foreseen to be inevitable. Education and diligence scholarship and learning, enjoying no privilege, are at a 29 discount: they are rather impediments than advantages. They interfere with the intolerant and arrogant pride of republican equality, and are therefore regarded with suspicion and dislike. I say it with pain and shame, with the profoundest mortification and the keenest regret, the influence of these circumstances upon our noble but depressed profession is but too visible, and it is to be most seriously feared that the medical character, already impaired in some of these United States, is deteriorating in all. We are loudly called on for an effort to restore and maintain it. Conventions and conferences, and ge- neral assemblies may depose an unworthy brother from the clerical dignity—the bar may expel a discreditable member by a public and official act of great force and weight—but we have no such resource. Our local societies are destitute of power, because those who are fearful of their control keep aloof from them. A National Medical Association, however, may, if well organized, well officered, and well conducted, through its branches, or affiliated societies diffused over our wide and still expanding territory, exert a most beneficial influence, inevitable and irresistible. I trust that the organization of such a body may be effected at the next meeting of the Convention, and would fain hope that the counte- nance and aid of our government may, in some consti- tutional mode, be extended to it; perhaps through a recognized connection with the National Smithsonian Institute. Meanwhile, let us endeavor to enlighten the judg- ments and arouse the proper feelings of our fellow-citi- zens upon this subject, by urging on their consideration the necessity of instituting some available method of removing the stigma under which we labour, and placing the practice of medicine upon a proper and honorable 30 footing. The suggestion of the Convention, as to this point, is unobjectionable. Let the business of teaching and licensing be separated—let the examinations be open to all. Let them be conducted by a Board of Examiners, selected in every State upon the most liberal principles, and constituted of eminent, well educated, and otherwise competent persons, without reference to sects or names, or opinions of any kind, but simply to charac- ter and qualification. Among the recommendations of the Parisian Medical Congress, of which I have spoken with not undeserved respect, we find something similar. " The admission and final examination of doctors should " be entrusted," they say, "to a jury, formed partly of " professors and regular examiners, and partly of prac- " titioners. The examinations of students should be "made even still more practical than they now are. In "addition to the five examinations already exacted, a 'sixth should be added on the subjects of Medical Phi- losophy and History." Surely such a body may be brought together, both impartial and every way trust- worthy. Among these, if proper individuals be found in their ranks, let every class of practising physicians, every school, so called, be represented; the Homiopa- thist, the Allopathist, the Botanist, the Hydropathist,the Hydropsudopathist, the Dypsopathist, the Expectant, and the Perturber, the Galvanist and Electro-Galvanist, the Magnetist, the Mystic, the Mesmerist and the Eclec- tic. Let the diploma of no college weigh with them, except so far as it is proved by experience to be confer- red exclusively upon diligence, character and merit. Let no patent right to play upon the credulity of the miserable be in any manner recognized ; no miraculous pretensions considered. Let them only, after the closest scrutiny and fullest examination of such candidates as 31 may present themselves, from whatever quarter, decide upon the important question of their fitness or unfitness to be entrusted with the physical care and protection of the community. Such is now the course of the general government with regard to our army and navy, upon whose official list no physician or surgeon can be ap- pointed, whether graduated or not, or from whatever college or university, without passing through an ordeal so strict, a scrutiny so thorough, that there is little fear of the intrusion of the ignorant or unfit candidate. And is it possible that any civic or municipal body or State can continue to treat this matter w7ith neglect or indiffer- ence ; or do we regard the lives of our soldiers and our sailors as worthy of more exact supervision, and more tender care, and deserving the devotion of a higher order of intelligence and preparation than those of our wives and children! The Board I have alluded to, in one of their reports, offer an explanation of the well known fact, that "com- " paratively a small number only of the candidates exam- " ined were found qualified for appointment." Observe, I pray you, the mortifying proportion of those who meet with success. In 1841, fourteen (M) were examined—approved but six (6) In 1842, ten (10) " " " " two (2) In 1843, ten (10) " " " " four (4) In 1844, seven (7) » " " " three (3) In 1845, ten (10) " " " " two (2) It is a most severe censure on our ordinary course of instructions, but not less merited than severe, (when we reflect, that the candidates were all of them graduates cf our recognized Colleges,) that the alleged causes of failure set down, are "insufficient preparatory education, " a hurried course of professional pupilage, and want of 32 "proficiency in practical anatomy, in pathology, and in " clinical medicine." I am destined soon to pass away from the professional arena: my labors with my life are almost at an end. Whatever of honor and distinction was attainable, I have struggled for with all my energies; but I have al- ways felt, that if I had in my hopes and aspirations, nothing more lofty or satisfying than the gratification of ambition, which Canning has pronounced to be " the only desirable thing in the world," the choice of my pro- fession would have been an infinite mistake. We may win the personal respect, the cordial esteem and friend- ship, and the sincere gratitude of our patients, and the circle to which we may belong. These constitute the principal solace, the delightful reward of our unequalled sacrifices, our constant toil. Far from detracting from their value, I am not willing to allow that theie exists a single individual to whose happiness they have more largely or essentially contributed. But I speak now of public consideration, of social position, of recognized weight, of distinction opeily conferred. Nothing of this sort, in these United States, beckons forward or cheers the heart of the physician ; there are for him no promises, no prospects of ultimate reward from the Commonwealth, Upon all her other children the republic smiles; for him alone she has not one single glance of official recognition or approval. The soldier, the sailor, the legislator, the inventor, the architect, the sculptor, the painter, each obtains the civic honors which he deserves; and let him ever wear them without envy, or jealousy, or detraction. But no wreath is twined for the brow of the physician; his silent labors go unheeded and unrecorded; confounded by the neglect of the law with the empiric and the ven- 33 der of nostrums, neither honor nor advancement in any shape are attainable by him, nor place, nor pension, render less wretched the decline of life or the incapacity of old age. I know how unpalatable the opinion that government should take charge of matters of science, and am well aware of the violent predominance in many portions of our republic, if not throughout all its borders, of the ab- surd and paradoxical notion, that "the best government is that which governs least;" but I have no fear or reluc- tance at being in a minority, and as long as I can speak at all, will denounce error wherever I meet with it. Contrast the course of the more enlightened nations of Europe in this matter with ours, and look at the results, and we can hardly fail to blush for the difference pre- sented in the two pictures. In those great centres of civilization, an honorable place in the body politic is assigned us. Our institutions are specially cared for, and protected by all such ordinances as our expert and aged brethren indicate to the constituted authorities. This is the fact every where in deep thinking Germany and intellectual Italy. In France—and where do science and art flourish as in France?—every thing is done to aid, to favor and to elevate us. A Medical Congress was lately held in that kingdom, at whose meetings the minister of public instruction—would to God that such a functionary had a place in our cabinet!—was a frequent attendant, and an intelligent hearer of the discussions, debates and suggestions. All honor to M. Sal van dy for the pure and lofty sentiments to which he gave utterance, while pledging himself that his government would exert its utmost ability to foster the divine art, whose advance- ment was the object of their assembling together. Where but among Frenchmen could the following 5 34 scene have occurred, most forcibly and graphically de- scribed by Pariset, in his Eloge de Larrey, lately read before the Academie Royale de Medicine de Paris. Du- ring the retreat from Moscow, as is well known, whole regiments, entire battalions of the wretched remains of the army sunk exhausted, blackening with their corpses the glittering surface of the desolate plains of snow which they traversed. In this disorganized crowd of living spectres, all soldierly discipline was lost. Pressed upon by a cruel, revengeful, and remorseless foe, and perish_ ing with cold, hunger, terror and disease, they approach a river. Two bridges are thrown across it, but afford very inadequate passage to the immense throng urged forward by the cannon, lances, swords and bayonets of the enemy. In the midst of the tumult, afar on the ad- vancing wave of human bodies, they distinguish Larrey! and even in this desperate struggle, a thousand cries are heard. "Save him who has saved us! Let him come! Let him approach!" The crowd opens, Larrey is passed over the bridge by the soldiery from hand to hand; he is saved, and almost immediately the overburdened structures yield, and are crushed under the weight which loads them, carrying down in their ruin, men, women children, soldiers, horses, and "all the pomp and circum- stance of war." In England also, there is at this time, as in France and here, much agitation and great anxiety for the im- provement of the Medical Institutions, and two or three different bills for the better regulation and general eleva- tion of the profession are before Parliament. And there also the ministry are under promise to carry into effect, any arrangements that may be pointed out and agreed on by the professional masses of the kingdom, as likely to exert that tendency. 35 In France, the Peerage is adorned by its bestowal upon Physicians and Surgeons of eminence, and portraits of these, her great men, decorate her national galleries with those of her statesmen, her warriors, and her men of learning, thus proving her claim to the true glory of the highest civilization, by rewarding alike the acts of peace, and benevolence, and preservation, with those of force, devastation, and destruction. In England, the aris- tocratic sentiment of her haughty nobility yields with far less readiness a place to science; yet, title and re- fwards are sometimes conferred upon a favorite. What is vastly more important, laudable, and impressive how. ever, some of the niches in the magnificent Parliament, house, now rising from the ashes of old St. Stephens^ are reserved for the statues of Harvey, Hunter and Jenner. Let such names and examples as these, gentlemen, always excite and stimulate you: and although I cannot promise you titles, places, public honors or distinctions as the rewards of your future exertions ; yet, if these are wanting in our humble sphere, we may well content ourselves with the far higher gratifications derived from the consciousness of duties fulfilled, of good actions per- formed from benevolent motives ; with the recollections of a well spent life, the filial trust in an approving God, and the confident hope of happiness beyond the grave.