ADDRESS ON STATE MEDICINE AND MEDICAL ORGANIZATION, BY THE “ANNUAL ORATOR” FOR 1879, 07 TIIE LOUISIANA STATE MEDICAL SOCIETY, ST'AXFOItD E. CHAILLE, A.M., M.D., PROF. PHYSIOLOGY Alii. PATH. ANAT.. MED. DEPT.. UNIVERSITY OF LOUISIANA. Ac. WITH THE RECOMMENDATIONS IN DEFERENCE TO S TATE MEDICINE OF THE LOUISIANA STATE MEDICAL SOCIETY AND OF THE ORLEANS PARISH MEDICAL SOCIETY TO THE LOUISIANA CONSTITUTIONAL CONVENTION OF 1879. NEW ORLEANS: PRINTED BY “THE DEMOCRAT PUBLISHING COMPANY.” 1879. ADDRESS ON STATE MEDICINE AND MEDICAL ORGANIZATION, BY THE “ANNUAL ORATOR ”, FOR 1879, OF THE LOUISIANA STATE MEDICAL SOCIETY, STANFORD E. CHAILLE, A. M., M. D., PROF. PHYSIOLOGY AND PATH. ANAT., MED. DEPT.,-UNIVERSITY OF LOUISIANA, &c. WITH THE RECOMMENDATIONS IN REFERENCE TO STATE MEDICINE OF THE LOUISIANA STATE MEDICAL SOCIETY ORLEANS PARISH MEDICAL SOCIETY AND OF THE TO THE LOUISIANA CONSTITUTIONAL CONVENTION OF 1879 NEW ORLEANS: PRINTED BY “THE DEMOCRAT PUBLISHING COMPANY.” 1870. NEW PROVISIONS IN THE INTERESTS OF STATE MEDICINE PROPOSED FOR THE CONSTITUTION OF LOUISIANA. On April 11, 1879, a committee of the Or- leans Parish Medical Society presented to the Louisiana State Medical Society the follow- ing recommendations for adoption by the Louisiana constitutional convention of 1879— stating that these recommendations had been revised by and had received the hearty ap- proval of every lawyer to whom they had been submitted; among these lawyers there were'four of the most eminent judges and jurists in the State. That the only discourag- ing criticisms made were: That these rec- ommendations could be provided for by the Legislature, and that they were at least fifty years in advance of public opinion in Louisi- ana. In reply to these objections It was urged that the recent constitutions of Texas, North Carolina, etc., presented precedents justifying the adoption of these recommenda- tions by Louisiaua; and that if embodied in our constitution public and legislative opinion would be thereby solicited to, and so gradu- ally enlightened upon these important inter- ests of the people. After due consideration these recommendations were indorsed unan- imously and emphatically by the Louisiana State Medical Society, which further resolved that an auxiliary committee be added to the standing committee of the Society on State Medicine, for the purpose of urging these recommendations on the constitutional con- vention. Dr. S. E. Chaille, of New Orleans, was ap- pointed chairman of the standing committee, Dr. John P. Davidson, of New Orleans, chair- man of the auxiliary committee, and the recom mendations are as follows: TITLE- STATE MEDICINE. Akt. —. The Legislature shall provide for the interests of State Medicine in all its de- partments ; for public hygiene or preventive medicine; for medical education; for institu- tions for the sick and infirm, and for medical jurisprudence: for the establishment and maintenance of a State Board of Health and Vital Statistics for the whole State, with par- ish or municipal boards subordinate thereto; for the protection of the people from all con- tagious and infectious diseases, and from all preventable causes of disease and death; for the protection of the people from .unqualified practitioners of medicine, surgery, widwifery, pharmacy and dentistry; for the mainte- nance of the University of Louisiana, and its three departments of literature, medicine and law; for the care, education and maintenance of the destitute, sick and afflicted, of the blind, of mutes, of idiots and feeble-minded children, of the insane and of inebriates, in hospitals or asylums, constructed with pioper regard to health as well as comfort and the interests of morality, such institutions being rendered as nearly self-supporting as is consistent with the purposes of their creation; for the protection of confidential com- munications made by patients to physicians; for preventing the advertisemen and sale of all foeticidal drugs or instruments, and of all drugs detrimental to the interests of health and morality; for the adequate compensation of scientific experts in ail cases; for the separate trial of criminals alleged to be in- sane on each issue—first that of insanity— and that adequate time and opportunity shall be given to medical experts to test the ques- tion of insanity. No persons shall be allowed to testify as expert witnesses to matters of scientific opinion, except those recognized as competent experts in such matters by their own profession, as organized under the laws of this State. Only qualified practitioners shall be expert witnesses in the courts to medical facts; the legal duties of coroners shall be assigned exclusively to experts in law, and their medical duties exclusively to experts in medicine. ADDITIONAL INSTKUCTION TO THE COMMIT- TEE. If any article of the constitution of 1879 pro- vides that privileges, to have effect against third persons, must be recorded, the follow- ing proviso should be made: Provided, that the fees due physicians and surgeons, the wages of nurses, and the bills of druggists and apothecaries, for pro- fessional services rendered, and medicines furnished during the last illness, shall enjoy the privilege conferred by law, even as to third persons, without recordation. STATE MEDICINE AND MEDICAL ORGANIZATION. ADDRESS ON APRIL 10, 1879, BY THE “ANNUAL ORATOR” OF THE LOUISIANA STATE MEDICAL SOCIETY, STANFORD E. CHAILLE, A. M., M. D., Prof. Physiology and Pathological Anatomy, Medical Depart., University of La. “ When lone in woods, the cringing: savage crept,” he could prove how bound- less was his liberty, by hands smeared in the blood even of wife or child: but men and beasts as savage and as strong, soon taught the primitive man civilization’s first great lesson, that he could barter part of his liberty in exchange for greater security to property and life, by submitting with his brothers to the rule of a patriarch. Like causes forced these patriarchs, combining many families into one tribe, to yield submis- sion to a common chief; and, progress continu- ing, these chiefs were forced, combining many tribes into one nation, to give allegiance to a king. Wherever social order has been se- cured and civilization developed, men have been thus forced in larger and larger masses to unite, have overcome obstacles in propor- tion to the strength of their union, and this strength has been proportionate to the intel- ligence and self-denial of the units; lor, al- though self-interest has organized every na- tion, as well as every union, yet, if these tri- umph permanently, the sell-interest must be sufficiently enlightened to comprehend that the individual’s welfare depends on the gen- eral welfare, and sufficiently ennobled to sa- crifice the good of one—even of one’s self—to the good of many. If the making of a nation thus depends on the union of larger and larger masses of men, its maintenance and progress are not less dependent on the redistribution of its united citizens into new co-operative groups— groups which multiply as civilization in- creases the interests of the nation and the occupations of its citizens. Every nation is forced to distribute its citizens in many dif- ferent groups; some must wield the sword, others carry its purse and others balance its scales of justice; while even those citizens, left by government undistributed, find their highest welfare in organizing voluntary associations. Every great private as well as public enterprise—whether in agriculture or commerce, in manufactures or mining, in politics or religion, in literature or art, in education or science—depends for success on co-operation, and on the strength of the bonds linking each unit to the whole. In fine, the history of civilization proves that man “can only make progress in co-operative groups,” ana that enlightened self-interest is their organizer. This effort to enforce the trite and briefer lesson, “in union there is strength,” would not have been made, except for the reasons that, while physicians have, with unanimity, constantly complained of the many and man- ifest defects in our laws, relative to medical matters, few have seemed to appreciate that these defects necessitate, for their correction, an efficient organization of the medical pro- fession; and still fewer have been willing to make the sacrifices necessary to secure such an organization. If to complain of evils with- out an effort to correct them is childish; if to know the remedy and not strive to apply it is folly; then the medical profession is lacking either in manly enterprise or in an intelligent appreciation of the importance of associated action and of the means to effect it. Therefore, the all-important problem to be solved by us, pioneers in or- ganizing in one society all reputable mem- bers of the regular medical profession in Louisiana, is, what can we, only a small part of the whole, do to gain our first great need, which is, to bind in one co-operative group all the physicians of this State? Manifestly we should appreciate the obstacles to success, and should our- selves not only understand, but should also force our professional brethren to understand, what good we would and could accomplish if their indispensable aid were given in securing union of the medi- cal profession. To some of the obstacles to be encountered, to some of the benefits to be conferred, your attention is solicited. History furnishes an instructive warning. The first “Louisiana State Medical Society” was organized in 1849, under auspices like those which originated its successor, this so- ciety ; for the project was initiated by a coun- try society,* and accomplished by the aid of the physicians of New Orleans. From birth its life was feeble, and, remaining in spite of its title a mere city society, it, after six years, died of “absenteeism due to the indifference and apathy of the country parishes.” Effort must be made to understand the cause-, if we would correct them, of that professional apa- thy, indifference and absenteeism, not only *I« 1849 bv the “Attakapas Medical Society” arid the “New Orleans Physico-Medical Hoeiety, in 1878 by r1' Plaquemines Parish Medical As- sociation,” and tne “Shreveport Medical So- ciety.” 6 Annual Address before the of the country but also of the city, which de- stroyed the preceding, and threaten the suc- cess of the present State Medical Society. The history of the thirty-seven state medical societies in the present thirty-eight states proves that the relative prosperity of these depend largely on the number of phy- sicians, the number of miles of railroad, and the density of population (especially near to the railroad fines) in the state. A fair com- parison as to these three particulai's shows that Louisiana, outside of New Orieans, stands at greater disadvantage than any other states except Colorado, Florida, Ne- braska, Nevada and Oregon. The tax on the time and money of the traveler, from parts of this state to New Orle.ans, is as great as from this city to New York, and yet there is no point in the state which presents for con- centrating an assemblage, traveling facilities comparable with those to New Orleans. City members can do nothing to diminish the tax on the time, but ought they not to do all they can to diminish the tax on the money of the country members? In any case, the pro- gress of our two railroads to Texas justifies strong hopes of the greater success of this society on their completion. Comparison further proves that, with few if any exceptions, the most prosperous state medical societies have owed their permanent success, some of them their origin, to the fostering aid of their legislatures, by which they have been chartered, authorized to ex- amine and license, and in various other ways assisted. Experience justifies the belief that, while state legislatures heed but little the often dissentient voices of physicians repre- senting a few scattered localities, important privileg* s and powers would be granted to even a majority of the profession if united in a State Medical Society. Every increase of privilege and power tends inevitably to in- crease the membership and influence of a society. Another serious obstacle to our success is presented by the deplorable facts that in this state about one-six'h of the white and seven- eighths of the colored voters—in fact, more than half of all the voters—“cannot write their names.” Ignorance spreads a pall of indifference and apathy far beyond itself. Men generally, even intelligent and ambi- tious physicians, strive rather for relative than for absolute superiority, and are prone to beeome content when manifestly superior to their associates, even if these “cannot write their names.” Hence the education of every citizen, black as well as white, is of in- finite importance to the success of this so- ciety, as of every other interest of the state. Ail the facts now enumerated tend to pro- duce that vital defect—paucity of members— from which ensue too little professional inter- est in the society’s action to stimulate the members to sucli labor as would render their sessions practically useful and attractive; too little power to enlist, as power always does, new adherents; and too little money to discharge the duty, most essential to the suc- cess of every scientific society, the publica- tion and dissemination of useful knowledge. An annual income of only $1000, expended in judicious publications, would rapidly increase both our membership and the value of our publications. It, however, must not be for- gotten, that while the dissemination of knowledge is our chief road to success, reve- nue and pubiication are also two rocks on which many medical societies have been wrecked, and require for their beneficent dis- posal the utmost caution and discretion. But the greatest obstacle to our success, the one to which all others are subordinate, is the inappreciation by physicians of the great benefits which would accrue to them, and at the same time be conferred on the people, by union of the medical profession. To illustrate these benefits, and also to prove that an efficiently organized medical profes- sion could secure them, are the chief objects of this address. You will not forget that this society has publicly declared that “the inaugurate n and promotion of State Medicine is a subject of unequaled importance to the material wel- fare and happiness of the people,” and that this great subject was the most important consideration prompting its organization. Then surely we ourselves should clearly un- derstand, and enable all others to understand what is State Medicine in general and in its details. The adjective-noun being used genericallv, as in statecraft and statesmanship, State Medicine is the application by the state of medical knowledge to the common weal, and embraces every subject for the comprehension of which medical knowledge, and for the exe- cution of wvich the legislative and executive authority of the government are indispensa- ble. Its bounds are necessarily as limited as may be the authority of the government, so that, in the United States, State Medicine is restricted, as to our national government, within very narrow bounds, within even nar- rower bounds than as to our county and mu- nicipal governments, while our state govern- ments have ample and undisputed authority over each of its four great subdivisions, viz: Publicn Istitutionsfor the sick and the infirm, Medical Education, Medical Jurisprudence, and Preventive Medicine or Public Hygiene. Are these vital interests of the people, of whom we are an integral part, worthy the consideration of our profession, the only class of the people now able to appreciate their importance? Or does it happen that the laws of Louisiana are on these subjects so enlight- ened that we can with quiet conscience refrain from efforts for reform? In truth, many states are far in advance of Louisiana, and it is those farthest to the front which resound the loudest with the incessant cries of our brothers for additional progress. No physi- cian whose heart vibrates in response to hu- man suffering and whose brain is sufficiently enlightened to appreciate State Medicine, can possibly submit apathetically, indifferently and without effort to the many remediable evils which beset us. An enumeration of, with comments on, the various subjects which belong to each one of the four great branches of State Medicine will suffice to remind you what are some of these evils and some of the defects ol our laws. PUBLIC INSTITUTIONS FOR THE SICK AND THE INFIRM. No state perfected its laws for the organization and support of its hospitals, dispensaries, infirmaries and sanitaria; of its asylums, which should be educational as well as medical, for idiots and feeble-minded Louisiana State Medical Society. 7 children; of its.asylums for the blind, for mutes, for the insane and for habitual drunkards. When will Louisiana have such a General Hospital as has Massachusetts, so excellent that even the wealthiest and the worthiest of the state seek its pay wards for their own relief ? When will Louisiana have an asylum, both educational and medical, for its idiots and feeble-minded children, such as has New York ?* When will Louisiana make such pro- vision for its insane that tender hearts will cease to be shocked by the woful reports of grand juries and boards of administrators ? And wnen will this state aid in rescuing thousands of wives more wretched than widows, thousands of children more wretched than orphans, from incurable druukards, by providing such an inebriate asylum, as New York was the first government in the world to establish in 1854 ? In fine, who in this state is there who has investigated this branch of State Medicine sufficiently to re- port to the people its needs and its defects, with the remedies therefor; and yet, on such reports depend the difference between the cruel suffering and the welfare of thousands of the most unfortunate of all our fellow creatures ? MEDICAL EDUCATION. The bliss of ignorance is proverbial, but what man can be content wno knows how inade- quately medical education is provided for, how deplorably the practice of medicine, of pharmacy and of midwifery is reg- ulated, and how inefficiently the people are protected from the enormous evils to health and life inflicted by adulterated and patent drugs and by mountebank doctors? Louisi- ana needs, as does every state, better laws, to regulate the practice of medicine, phar- macy, midwifery and dentistry; to estab- lish, organize and govern medical colleges; to encourage and support medicai libra- ries, museums, laboratories and botanical and zoological conservatories; to promote original research; and to facilitate ana- tomical and other medical studies to the ut- most. Except in the last particular Louisiana is inferior to many of the states, none of which can be compared in these particulars with France, Germany or Great Britain; but there is no good reason why we should not at least strive to equal, in all good things, any nation on earth. Of the various subjects appertaining to medical education, two are now profiting by professional attention, viz: the regulation of the practice of medicine, in order to suppress quackery outside of the profession; and col- legiate education with final examination, in order to suppress the same great evil inside the profession. Since these topics, however trite, must be discussed until disposed of by satisfactory action, you will pardon a brief allusion to them. Although medical literature, including the transactions of State Medical Societies, abound in d’scussions, I have searched in vain for a single article on laws to regulate the practice of medicine in any wise exhaustive, or worthy of the subject; which serves to illustrate what little attention is yet given to State Medicine. For instance, few of our impatient reformers seem aware that, until about 1840, every state then in the Union, except Pennsylvania, Virginia and North Carolina, had had the now much desired Medical Examining Boards, appointed in some cases by the Governor, but in many other cases by the regular medical profession itself, through state or county medical societies; and that these boards did not prove satisfac- tory to the profession, and so unsatisfactory to the sovereign people that their representa- tives, in nearly if not quite all the states, did, from about 1840 to 1852, repeal or annul all the laws establishing such boards. Surely, if we would profit by the experience of our fathers, it is indispensable for us to know all the causes of their failure, and yet not one of those advocating reform adequately supply this knowledge. Still farther, North Carolina since 1859, and a few other states have on this subject old laws still unrepealed; and since 1873 at least six states* have enacted new laws, and yet I have searched in vain for an instructive report as to the comparative merits of these laws and as to their operation, whether satisfactory to both profession and people, and whether likely to be improved by amendments or to be repealed. Surely knowl- edge of this kind is very requisite to guide us rightly, and to guard us from retarding, in- stead of promoting, the very progress which we seek—an evil which often ensues from in- considerate legislation. Some study of the legislative history of this subject justifies the folio wing conclusions and suggestions: It is worse than idle to seek leg- islation which would debar from practice homoeopaths, eclectics or other practitioners of any special or exclusive system of thera- peutics, because no such law could be exe- cuted, if enacted. Our fathers, as has been stated, had such laws, which were all repealed, for the chief reason apparently that it was attempted to enforce them. Begular physicians enjoy unmolested their system of practice and their code of ethics, and expe- rience proves that the public intend to main- tain an equal right to test the demerits of other systems and codes, and to leave error free in its combat with truth. This resolve is implanted so deeply in the hearts of our voters that Texas has enthroned it in her con- stitution, which solemnly declares that “the Legislature may pass laws prescribing the qualifications of practitioners of medicine in this State, and to punish persons for malprac- tice ; but no preference shall be given by law to any school of medicine.” If therapeutic systems jvere disregarded, we could probably induce the people to protect themselves from unscrupulous medical tramps and ignorant adventurers by laws prescribing that no per- son, unless found qualified by education, shall practice medicine; but then arise these, as yet, unsolved questions: By what method shall the qualifications necessary be deter- mined, and by what means shall the penalties for violations of the law be enforced? Having no confidence in the discharge of laborious official duties by voluntary and unpaid offi- cers, I find no answer to these questions ex- cept in adequately paid officials, whom it is Connecticut, Illinois, Kentucky, Ohio. Penn- sylvania and perhaps o her states are reported to have schools for idiots and feeble-minded children, but I do not know whether these are or are not state institutions. * Alabama In 1877. California 1876 and 1878 New HamDShire 1876. New York 1874,'Texas 1873 and 1876, Vermont 1876 and 1878. 8 Annual Address before the not probable any legislature will grant for many a day to come. The ripest civilization, from which we, with like language, laws and institutions, can gather fruitful lessons, is that of Great Britain, and I believe that our road to pro- gress in this subject of State Medicine, as in many others, is by the path “blazed” by the British Parliament. The British Regis- tration Law of 1858 is reported to have oper- ated admirably. It is executed by a “General Council of Medical Education and Registra- tion,” composed of twenty-four officers des- ignated by law, and paid—paid, as I infer, ny the British Medical Association. It is based on the principle that “it is expedient that persons requiring medical aid should be en- abled to distinguish qualified from unquali- fied practitioners.” Those whom we desig- nate irregulars are, if found qualified by the council, registered equally with regulars. Fraudulent registration is liable to severe penalties. No physicians, except those registered, are recognized by the courts; are exempt from jury and militia duty; and en- joy the right to practice and collect fees, to sign legal certificates, to testify in courts as experts, and to' serve as medical officers in the army, navy, and civil service. Such is the pith of the only law ever yet enacted on this subject by any English-speaking people, which, tested by experience, has proved worthy of our imitation. Louisiana has had, since 1861, a registration lawt—poorly devised, inefficiently executed— but will it not furnish an entering wedge to progress, and ought we not to direct our efforts to amendments of this law? And ought we not also to seize some one of the many opportunities presented to test on medical impostors the value of that act of 1872 and 1879,t which declares: “Any physi- cian, or pretending physician, who shall falsely pretend to have been a professor of any medical college, or to hold literary or professional titles to which he is not entitled shall be forever barred from the right to prac- tice medicine in this state, and on failure to supply evidence to substantiate any claim to such title by proper diploma or other docu- mentary or satisfactory evidence, shall, on conviction, be imprisoned in the State Peni- tentiary not less than six months or more than five years.” The fact that out of 270 practitioners of medicine now in New Or- leans ninety-three of them are, as is reported, irregulars or quacks, should stimulate us to efforts for reform. As to the subject of collegiate instruction with final examination, it is unnecessary to detail the numerous expedients which have been adopted or are now under discussion to promot-* progress in this direction, nor will it be denied that some of these are calculated to palliate present evils; but the only effectual remedy, in my opinion, is the total divorce of medical instruction from the right to confer a diploma, which of itself confers the legal right to practice medicine. The professors of a medical college should not constitute a legalized Board of Medical Examiners; but it must not be forgotten that to annul this power in one state might now destroy any unendowed medical institution of such state, so that action seems dangerous, until at least a majority of those states wtiich have pros- perous medical colleges can be induced to co- operate. MEDICAL .TUKISPRIJDENCE, OI{ FOBENSIO MEDICINE. Neither Louisiana nor any other state can challenge intelligent approval of their laws on the following subjects: Medical Witnesses. — In at least three particulars the laws generally are defective: for they fail to adequately provide competent physicians to act as ordinary witnesses to medical facts, such as are derived from pro- fessional examinations; they fail most grossly to provide that expert witnesses to medical opinions shall be furnished solely by veritable medical experts; and they fail to provide ade- quate compensation for medical experts. Further, the laws are defective as to the insane, to inebriates, to poisoning, to infanticide and criminal abortion*, to the viability of the new-born infant, to protec- tion of confidential communications by a patient to his physician, and to malprac- tice. A brief consideration will be given such of these subjects as are now exciting medical discussion. In some of the oldest and most densely inhabited states, where are invariably de- veloped evils unknown in states sparsely populated, malicious suits, professedly for malpractice, but really for blackmail, have grown to such an evil, that in 1878 the Maine Medical Association resolved “that, with the existing laws on civil malpractice, it is unsafe to practice surgery among the poor.” Appa- rently, out of 600 physicians in the state, 125 have been prosecuted. The legal remedy sought for is, “bonds compelling the plaintiff, in case of defeat, to pay the taxable costs.”f Other societies have recommended that all suits for malpractice should be tried by a special jury of physicians. From the same class of states the report is often repeated that criminal abortion is cons- tantly and alarmingly increasing. A member reported to the Maine Medical Associationjthat the cases annually were not less i han two thou- and, while a member of the Wisconsin State Medical Society reported in 1870 that no phy- sician would dispute that, “where one living child was born into the world, two are done away with by means of criminal abortion.” Most medical societies demand better laws, but others report that the evil in their states is due, not to the laws, but to their inefficient execution; and, in confirmation of this, the report from Maine is that “it is impossible to get an attorney to prosecute, or a jury to convict, an abortionist.” Defects of the laws as to the insane are to be found in every state. Though numerous and grave, allusion will be limited to two of these defects. In some of the states, while ♦Thelaws of some stages still bear the im- press of barbarous origin, in regarding only the “quick child,” (Miss. Mo., and no doubt others), as a living human being: and in select- ing a j ury of old women to determine any ques- tion as to the pregnancy of a criminal. tMe. Med. Assn. Trans. 1878, and specially the excellent article of Dr. Sanger. f See snctionev2677, 2678. 2679 Revised Statutes ot Louisiana, 1870. t See the final clause of the seventeenth para- graph of Act No. 14, page 51, Acts of 1872, repeat- ed on page 43, Acts of 1879, sixteenth paragraph of section l. Act No. 27. Louisiana /State Medical Society. mitted for decision to those unable to esti- mate its weight.” I cannot leave this subject of medical wit- nesses, without recording the greatest triumph yet accomplished by American Medical Juris- prudence, a triumph whicn, on this subject, places Massachusetts in advance of every English-speaking people. For, of these, all others still maintain that insult to medical, as it is to legal science, the medico-legal office of coroner; who, common sense dictates, should be both a medical and a legal expert, but whom our medieval laws encourage to be neither. Louisiana makes herself, in this matter, exceptionally ridiculous by enacting the superfluous negation, “that it shall not be necessary that he (the coroner) shall have had a medical or surgical education, or have been a regular practitioner of either branch of science.”* On the other hand, Louisiana has wisely required from every coroner an annual s'atistical report to the General As- sembly, but though such a consolidated report would prove extremely instructive, and tend, as it has done in England, to des- troy all respect for the coronor’s office, who ever saw such a consolidated report, or ever heard of the execution of this law?f But, returning to the instructive example of tri- umphant progress, permit me to report, that on October 4, 1876, at a stated meeting of the councillors (delegates) of the Massachusetts Medical Society, it was “voted that a com- mittee of five be appointed, to take into con- sideration the defects of the present laws rel- ative to the appointment and practices of coronors, so far as these delects involve the medical profession, and to report at the next meeting what action, if any, is desirable.” At the next meeting, February 7, 1877, this action was strengthened; and at the annual meeting, June 12, 1877, the committee repor- ted that it had “met with speedy and remark- able success.” In fact on May 9, 1877, the Governor had approved “an act to abolish the office of coroner, and to provide for medi- cal examinations and inquests in cases of death by violence.” The pith of this law is as follows: While coroners had been required in Massachusetts—as they now are elsewhere— to discharge the incompatible duties of medi- cal examiner and judge—that is, of an expert medical witness and of an expert judge of law—Massachusetts has now divorced this ill- assorted union of centuries; has created the “Medical Examiner” for the performance of one duty, and has transferred the other to the judges of the courts, and has specially enacted that “whether a homicide has been committed or not is a medical question, and whether that homicide be the result of accident, or be justifiable homicide, or manslaughter, or murder, is a legal question.” Thus, laws sanctified by centuries of here- ditary prejudice and of barbarous precedent, have, in Massachusets, been at last beheaded by tne slaughtering axe of common sense, which emphatically claims that the coroner’s medical duties should be assigned exclusively to a competent medical expert, and his legal duties as exclusively to a competent legal ex- pert. Hail! to Massachusetts, which heads the cheerful funeral procession to the coro- the alleged insanity of a criminal, and of a dead man who has left a will, must be decided by a jury, yet one or more of such doctors, as the laws so loosely recognize, can issue a certificate which will consign an innocent living man to an insane asylum, which to him is virtually a penitentiary. It is believed that as yet Maine, New York and Wis onsin* are the only states which have provided wisely for the trial of criminals alleged to be insane. The question, whether a court can force a medical expert to testify without securing him adequate compensation, has in recent years excited so much interest that medical societies have even resolved to raise the issue and force the courts to a decision. This was done in Indiana, ami the following facts are pertinent to this question. English courts have decided that a scientific expert need not attend a subpoena, that his testimony cannot be forced, and that he must be compensated. In 1877 the Supreme Court of Alabama de- cided to tne contrary; hut, also in 1877, a cir- cuit court of West Virginia concurred in the English view; in 1878, Judge Clark, in the case of the “State of Texas vs. Jasper Weathers,” decided that lie “knew' of no law to force a physician to attend court, and tes- tify as ail expert, without compensation;” and, aiso in 1878, the Supreme Court of In- diana, reversing the decision of a lower e >urt, maintained the expert’s right to compensa- tion.)- The Iowa Code of 1873 (and probably the laws of some other states) wisely pro- vides that “witnesses called to testify only to an opinion, founded on special study or expe- rience in any branch of science, or to make scientific or professional examinations, and to state the results thereof, shall receive ad- ditional comDensation, to be fixed by the court, with reference to the value of the time employed, and the degree of learning or skill required.” This law grants all the medical profession demands. Questions, however, referring to expert medical evidence, far more irnporta nt than this to justice and to the interests of the peo- ple, are—whom should the law recognize as experts, how should these be selected, and how should their evidence or decision be ren- dered? In this matter the laws which, when first enacted, may have been justifiable or ex- cusable, have now, in consequence of the vast progress of medical science, become a mere mockery of justice. In proof of this I will repeatj here that which I intend to repeat on every appropriate occasion—that, “as a gen- eral rule,” it has been adjudged by the state courts of this country that any practitioner of medicine (that is, any man who dubs him- self doctor) has sufficient knowledge of med- ical science to furnish justice with its “best attainable evidence;” and that, as results of our laws, “the power of medical science, crippled at the coroner’s inquest, is prostitut- ed by the partisan opinion of incompetent ex- perts, then perverted by advocates, and at last, when emasculated of ali vigor, is sub- *Se“ chapter 191, Revised Statufes of Wiscon sin. 1878. tSee two exc U«nt articles on ‘ The Medical Witness,” by Or W. Hobbs, Trans. 1877 and 1878, Iodiana State Medical Society. tSee Author’s Address on Medical Jurispru- dence. “Trans. International Medical Con- gress.” Philadelphia, 1876. *Section 150, Revised Statutes of Louisiana, 1870. tsection 672, Revised Statutes of Louisiana, 1870. 10 Annual Address before the ners’ grave; the tombstone should have en- graved on one face “Monstrum horrendum informe, ingens, cui lumen ademptum”—and on the other “God hath numbered thy king- dom and finished it; thou art weighed in the balance aud found wanting; thy kingdom is divided and given to ” the doctors and the judges. The results of this novel law, not yet perfected by experience and already once amended, are more harmonious, successful and economical than the results of the anti- quated laws repealed, and an active Massa- chusetts Medico-Legal Society has been stimu- lated into existence. As no science is more progressive than med- icine, so on no men, more than on physicians, is it oftener and more incumbent to “honor him to whom honor is due.” Theo. H. Tyn- dale, Esq., of Boston, is, I am assured, the enlightened operator who, subjecting his patient, the Massachusetts Legislature, to judicious preparatory treatment, met with “speedy and remarkable success” in the un- precedented operation of excising this foul tumor from the body politic. If a surgeon, by accident or skill, succeeds iu a hitherto unsuccessful operation, the plaudits of the profession reward him, even though the ope- ration be not calculated to confer a fraction of the benefit which will ensue from that opera- tion, which, by the advice and aid of the Massachusetts Medical Society, was per- formed by Mr. Tyndaie. That both operation and operator are so little known to and honored by the profession, proves again how little real interest is taken in State Medicine. That both may be better appreciated, it should be known that since 1875, if not longer, the British Parliament, prompted by the British Medical Associa- tion, has fuily recognized the disease and has agreed to operate, but has not been yet able to decide upon the mode of operation. Mr. Tyndale’s method is, however, as eminent for its simplicity as for its success. Yet a Lou- isiana legislature could not apparently now adopt it, since Article 93 of the Constitution of 1868 requires that coroners “shall be elected,” etc. PREVENTIVE MEDICINE, OR PUBLIC HYGIENE. No one of the four branches of State Medi- cine involves the public welfare to so enor- mous an extent as Preventive Medicine; a birth of this century, generated by the con- viction, forced on us by centuries of expe- rience, that the bounds of curative medicine are very restricted, and that the faith of our fathers in the discovery of an elixir vitae, or of a panaeea, was the baseless fabric of their imaginations. So important is Public Hygiene that there is in our profession a strong ten- dency, against which this address is an ear- nest protest, to consider it synonymous with State Medicine, of which it is only a most es- sential branch. So paramount in importance is Public Hygiene public good that Hr Bowditch estimates this country's annual deaths by preventable diseases to be not less than one-fifth of our million total deaths; while many authorities will concur with me, that an estimate of from one-fourth to one- half would more nearly approximate the frightful truth. Accepting the lowest esti- mate, experience seems to prove that there are many whose imaginations are too slug- gish to respond by action to the dry statis- tical fact that 200,000 people die annually in the United States by avoidable diseases. It may aid some to realize all that this dry fact implies, if “the mind’s eye” conjures up a vast array, the more horrible because avoid- able, of unnecessary doctors, nurses, drug- gists, undertakers, anguished parents, home- less widows and destitute orphans. It implies a great reduction iu the normal duration of life, and thereby the loss of inestimable benefits; such benefits as a community would now be deprived of if a large proportion of the men, at present from forty-five to sixty years of age, had been swept into their graves prior to tins period of their greatest useful- ness. It implies far greater public injury than would result from the diminution of im- migration to the extent of 200,000 annual foreign immigrants. And, if the aver- age value of a freeman’s life equals $500, or the value of a slave’s, and if the time of those sick and attending on the sick has an average value to the community of fifty cents a day, then my dry statistical fact no longer implies but proves an annual national loss by preventable disease and death exceeding $200,000,000! This communi- ty painfully realizes its loss by one year's epidemic, but, like other communities, it suf- fers every year as great a loss, which from ignorance and habit it cannot realize. Were our cotton crop destroyed, exchange, forum, press and even the pulpit would resound with lamentations and with active expedi- ents to prevent the recurrence of such a dis- aster, and yet preventable disease and death annually inflict a damage, which, though un- realized, is very real, greatly exceeding in money value the profits on the whole of our annual cotton crop. Why, in this case, is there neither public lamentation nor action? Because, public teachers nave, for many gen- erations, been in the habit of insulting our Creator by attributing to His malevolence evils real I v due to our own ignorance and to our own filth. Charity cries: “Lord forgive them; they know not what they do!” What should the public be incessantly taught? First, the inalienable right of every human being to be supplied with uncontam- inated air, water, food, soil and personal sur- roundings; and the duty of the state to allow no trespass on this right from negligence, igno- rance or greed of gain. Secondly, that the causes of many diseases and of many deaths can be as successfully fenced out from their human crop, as domestic animals, can be fenced out from a grain grop; and that, as powder and • other explosives are by law stored away and guarded, so, as one instance only, a small-pox pustule, potent with greater mischief than a magazine of dyna- mite should be, for greater reason, stored away and guarded. Aud last, but not least, that “public health is public wealth;” aud therefore, the public which organizes vigoi- ouslyaud spends money lavishly to vanquish Indian and other marauders, should make as efficient war against conquerable morbific foes, which, though invisible, are more disas- trous to both life and property. After many years of special study each ad- ditional year has increased my conviction that wherever social order has been firmly secured bylaw, there the supreme subject of importance is. The avoidable causes of dis- ease and death, their extent, cost and influents Louisiana State Medical Society. 11 on morality and human progress, This subject is so exhaustless, so varied in detail, so fruit- ful to study and discovery and so little under- stood by the public that I confess my impa- tience wlieuever a physician discourses to a public audience on any other subject; for it has been wisely taught that “the art of politics (an art essential to the progress of State Medicine) is to try to get ideas stamped as deeply as possible into, and spread as widely as possible among, the masses.” Germane to these views are the glad tidings that on March 31,1879, the Citizens’ Auxilliary Sanitaiy Association of New Orleans was or- ganized—auxilliary in matters of public health to our public officials. This evidence of non- professional interest in Public Hygiene is very encouraging, but experience warns us not to be too sanguine, and that it will require at least one year without an epidemic of yellow fever, to test the earnestness and the en- lightenment of this association. For, ten years ago, I ventured to warn the public that “every year without a yellow fever epidemic was a year nearer to it,” and added that “our press seems now to wait with inactive silence like its patron the public, for another over- whelming pestilence, such as the great epi- demic of 1853, which galvanized them into a few spasmodic efforts resulting in some ill- digested and worse executed laws, a quaran- tine satisfactory to neither contagionists nor auti-contagionists, and an impotent board of health utterly powerless to enforce those things needful for the public health.” The overwhelming pestilence of 1878 has come and gone; it has galvanized the public into efforts which, it is to be hoped, even the com- ing year may serve to prove are not merely spasmodic, for four of our greatest epidemic years, (1839, 1847, 1858, 1867), during the past forty years have not heen followed by an im- mediate successor. Persistence in sanitary reform, in spite of the absence of epidemics, is the only test of the enlightenment of the re- former. In addition to the organization in New Orleans of a Citizens’ Sanitary Associa- tion, another cause for great exultation is presented in a fact which inspires the hope that the disastrous epidemic of 1878 may yet prove to be an infinite “blessing in disguise.” This fact is the recent appropriation (on March 4, 1879), of $50,000 by Congress to es- tablish at last a “National Board of Health.” But I have wandered somewhat from my theme, which strictly is, what are the various subjects which belong to Public Hygiene and require better laws. The needs of this state and of others will now be indicated. An efficient State Board, strengthened by auxiliary local Boards of Health,and the Regis- tration of Vital Statistics, which includes the registration not only of marriages, births and deaths, but also of prevailing diseases, are fundamental necessities, with which not a single state is as yet adequately provided; and yet some states* have laws on these and other subjects to be mentioned, much supe- rior to those of Louisiana. Health is pre-eminently essential to happi- ness and usefulness, and to guard it some special knowledge is requisite; yet a knowl- edge of the elements of hygiene—a knowledge much more important and more easily ac- quired than geography—is so far from being taught in the public schools of the state, that even the teachers know nothing about it. Purity of air is man’s prime requisite, and purity of water is only second in im- Dortance; yet not a state has laws adequately providing these, nor to repress the increasing evils of adulterated foods. Insanitary occu- pations, offensive and unwholesome disposal of the dead, and many other sanitary nui- sances receive little attention from either the people or their lawmakt rs. Every large city has tenement or other crowded houses for the poor, so constructed that it is not possible for the occupants to be either healthy or ctiaste, and in which children from their birth are seized in the remorseless arms of this age’s Three Furies—tilth, disease and crime— yet so far are our laws from regulating the healthy construction of dwelliog-nouses that this is not done even for public edifices; no, not even for the public schools of our chil- dren, thus educating them in anti-hygiene. Not a state has laws encouraging, for sani- tary purposes, either drainage or irrigation. Massachusetts in 1840 effected a sanitary topographical survey, which proved of great value, and a second one was in 1875 instituted hy New York; but other states haye neg- lected this important matter; and, instead of guiding the immigrants, whom they seek to entice with trust worthy health maps; they supply him with the seductive but false certi- ficates of ignorant residents, who base their worthless convictions on such facts as that they are not dead yet, and that several of them, who, however, never happen to have about them a legal record of the date of their birth, are one hundred and more years old! Some states have laws to protect property and life from explosive illuminating oils, but, in most of these states as in this, the greed of gain has so emasculated these laws, that property is still endangered, while health and life are sacrificed. Bowditch* reports that while eleven states have laws which served to protect one species of four-footed beasts from the “Texas cattle disease,” only twelve [states have laws to pro- tect the human species of bipeds from yellow fever, sixteen from cholera, and twenty-one from small-pox. All know how defective, both in the letter and in execution, these laws are as to the preceding and all other con- tagious and infectious diseases. Thus far medieval prejudice has defeated all efforts to stamp out syphilis. This dire disease, which afflicts the innocent and the unborn as well as the guilty, is reported to have increased to such extent that its victims are computed to now number as many as one in every twenty of the population. What can be done? I have for years advocated (in my professorial lec- tures) one measure which should be, and I doubt not will be eventually adopted—a meas- ure which received in 1878 the advocacy both of the President)- and of an able essayist! of the Maine Medical Association. The measure thus advocated is the castration, or spaying, not only of the syphilitic, the leper, the idiot, and the habitual criminal—when found guilty of indulging in sexual intercourse—but also * Some cities have an efficient registration of vi'al statisti s. except of prevailing diseases; of the States, Massachusetts and Rhode Island have the best. * "Rygiene in America, 1877,” a vade mecum of the American sanitarian. t Dr. Gerrish and Dr. G. F. French. Trans. 1878. Me. Medl. Assn, 12 Annual Address before the of all other persons who would with certainty transmit to their progeny the irreparable curse of a corrupted organization. There is no debt to posterity more obligatory than is this. The laws of our pious grandfathers used this penalty to punish evil-doers who inflicted on society far less evil than do those for whom the resuscitation of this penalty is now advocated. Such is a brief and partial record of the various subjects appertaining to Public Hy- giene, subjects illustrative of the needs of the people, and therefore demanding the ad- vocacy of an organized medical profession. But common sense, discouraged by innumer- able evidences of popular ignorance, rudely awakens us from dreams of a sanitary Uto- pia, and commands us to concentrate our strength on the reforms most practicable and necessary. The reform now most necessary is the establishment of n efficient State Board of Health, having control of an efficient system for the Registration of Vital Statistics. On these two topics some additional informa- tion and suggestions will now be submitted. The value of vital statistics is so little ap- preciated that the medical profession should familiarize itself with arguments to convince the public of their value, not only in refer- ence to the rights of property and other ju- dicial requirements, but also in reference to their infinitely greater value for sanitary purposes. Public Hygiene derived its birth from and depends for its future progress on vital statistics, and every argument which favors the establishment of boards of health is an argument in behalf of vit al statistics, for, while a board of health without them is as helpless as is a man without eyes to guide him, so, without vital statistics the public is destitute of the only valid test of the value of a board of health. If a human being is much more valuable to the state than is a bale of cotton, then statistics of the human crop would prove much more valuable than statis- tics of the cotton crop, .and yet every news- paper can and does furnish statistics as to the cotton crop, such as no man can now anywhere procure as to our human crop. Vital Statistics furnish unerring lessons as to the health, prosperity and morals of the people; they teach the influence of marriage on illegitimacy and morality; the fecundity of the whole people and of the races there of; the vital force of the children; the duration of life, with its expectation and value, for all ages and races; the influence of meteorology, occupation, locality, in generating disease and improving health, and thereby the re- moval of unfavorable conditions, always found, even where least suspected; and the approach of morbific storms, by ignorance of which negligent cities and even nations have been destroyed The only foundation of life insurance, Vital Statistics serve alike to guide the residentand the immigrant, the capilalist and the laborer, the politician and the states- man, the moralist and the scientist. Ignored or disparaged by the average American state-legislator, they have been advocated and supported by Rapoleon and Thiers, by Bismarck and Cavour, by Gladstone and Disraeli; and their establishment has become a test of the degree of civilization reached by a people and their rulers. Louisiana needs the warning that the ex- perience of other states has abundantly proved, that trustworthy reports of vital sta- tistics cannot be obtained from the voluntary action even of medical men ; that an ade- quate penalty must, in case of negligence, be enforced on all from whom the law may re- quire reports; and that a competent, paid, medical official, to receive and compile the reports, is indispensable. In regard to State Boards of Health, the following facts deserve to be better known; after thirty vears of effort by the medical profession, Massachusetts, in 1869, legislated into existence the iirst State Board of Health and Vital Statistics organized in the United States. This prolonged effort was no doubt used in conciliating that legal maxim, which declares that “no law can successfully precede its public sanction,” and serves to explain, at least in part, the pre-eminent success of this board. However, the Governor did exercise, in the choice of members of the board, an amount of discretion very unusal to politi- ticians, when acting in medical matters; and the legislature, begining with an experi- mental appropriation of $8000, for the first year, has rapidly trebled it. The acknowl- edged superiority of this boaid is sufficiently proved by this fact, among many others, t hat it did at once recognize that the greatest obstacle to sanitary progress was popular ingorance, and therfore that its primary duty was to teach the people. Hence, it at once organized a corps of reliable correspondents throughout the state; it solicits reports from, and issues circulars of information to, all the doctors, preachers, teachers, county and state officials, newspapers and journals in Massa- chusetts; and, in addition, it issues and freely distributes more than 10,000 copies of the most vauable Annual Health Iteport ever pub- lished in this country. Thus by enlightening the public it has gained its favor, and has thereby increased its own power and the bounty of the legislature. So great is this power, that it triumphed over a tinancia' com- bination of fifty slaughter-houses, and con- verted these health and life destroying nuisances into sanitary blessings; it made war in Boston on the pestilence-breeding “houses of the poor,” and thus so alarmed the politicians, who loving their country much, love votes, even of the sick pauper, more, that the board summoned to its sup- port a mass meeting of the people, and was sustained. Some few of the other eighteen State Boards of Health—notably that of Michigan—increase the hopes inspired by Massachusetts’ exam- ple; but it is a sad truth that a ma jority of these boards are,'through legislative or gu- bernatorial action, mere burlesques ou sani- tary science. Louisana has legislated on paper a State Board of Health and Vital Statis- tics; but in reality we have no state, merely a city, board of health, organized under laws which nobody except politicians (and a design- ing or an ignorant class of these) can possibly approve. The efforts of the “legislative com- mittee’, of this society to improve these laws deserve careful consideration, probably our sup port. If consolation is derivable from the superior folly of others, then Louisiana is consolable; for some other Jstates have cer- tainly surpass'd her. Georgia, Virginia and, alas! my native state, Mississippi, have leg- islated State Boards of Health into existence, have imposed on the officers onerous and ex- Louisiana State Medical Society. 13 pensive duties, and then have appropriated for the execution of these laws, and the dis- charge of these duties—nof one cent! But, in any record of legislative quackery, North Carolina cannot be omitted, for her legisla- ture, apparently emulous to humiliate Vir- ginia, (1871), Georgia (1875) and Mississippi, (1877), passed a similar law, (1877), requiring the discharge of equally onerous and expen- sive duties, and then enacted “section 5,” which deserves a prominent place in that San- itary Museum, wnieh we some day will have, as Great Britain now has. It reads, “For the purpose of defraying the necessary expenses of the board of health of the State oi North Carolina in the discharge of its official duties, there shall be paid annually out of the treas- ury of the State to the treasury of the said board of health, upon the requisition of the president and secretary thereof, the sum of one hundred doldars ! !”* None the less, another legislature has surpassed all these in ludicrous legislation. For years the Maine Medical Association has been in vain solicit- ing a board of health, which, however, it will very certainly soon get, because it is using all such means as public lectures, newspa- pers and journals to teach the people. About 1876, the doctors urged on the legislature, among other things, the argument that, inas- much as the state paid annually $4000 bounty on wolves and bears to protect its sheep, its human animals were entitled to similar, even if to less favor, to protect them from such wolves and bears as variola and scarlatina. The Solons of Maine, by scratching their per- plexed heads, at last appreciated the logical bait prepared by cunning doctors to ensnare them, and having concentrated the full force of their juridical minds on devising a con- sistent method of escape from the trap, they triumphantly enacted an immediate repeal of the bounty on wolves and bears; thus leaving wolves, bears, voters and sheep un- molested by the equal hand of justice in their “struggle for existence.” The four par- ties interested were all deprived of farther right to complain of “class legislation,” but there can be no doubt that the sheep of Maine have ( oncluded that “too much legislation is dangerous.” Thus far, effort has been made to illustrate the benefits to the profession, and to the people which this society should seek to confer; and now much briefer considera- tion will be given to the last portion of my subject—to proofs that these benefits, which, in a free country, have never been attained by other means, can be conferred by an or- ganized medical profession. What has been effected by the 20,000 physi- cians of Great Britain will serve, in part, to prove what might be effected by the 60,000 physicians of these United States; and be- cause of like language, laws and institutions, the successive steps by which Great Britain has made its noted progress in State Medi- cine are worthy of our special study, since through like progressive steps must we ad- vance. In 1832 310 physicians founded the British Medical Association,which, extending now its arms by thirty-one Branch Associa- tions into every part of the three kingdoms, numbers more than 7000 members; and, though these pay an annual fee of only $5, the revenue of the Association amounts to $50,000.f What power has it gained over, and what benefits has it conferred on the profession and on the public? It has promoted friendly intercourse, and thereby strengthened the iinks binding the units to the mass; it has gained immense control over medical ethics, and thereby established a high standard of professional conduct, and greatly increased both its social and its political influence; it has fostered scientific debate, as also greater accuracy in cliniaal and all medical studies; in addition it appropriates some $2000 yearly for pro- moting original researches, which exalting the profession have blessed humanity, and thereby it has vastly stimulated the progress of medical science. It has raised by volun- tary subscription a “benevolent fund,” which yields more than $3000 annually, and thereby it constantly contributes “temporary relief to distressed medical men, their widows and orphans.” It did in 1853 establish, and in 1866 greatly improve, its weekly official organ, that noted first class pe- riodical the British Medical Journal, and thereby it has constantly instructed and stimulated its members—furnishing this valuable journal without cost—has increased its membership since 1866 at the rate of 500 annually, and has added a large surplus to the revenue derived from the annual fee of its members. But, great as are these benefits to the profession, they are insignificant when compared with those conferred on the public. Pari passu with tue progress of the Brit- ish Medical Association, medical and sanitary measures have been forced upon the attention of Parliament, and are now receiving from this enlightened body more consideration and wiser action than given by any other national legislature. Parliament, influenced by the British Medical Association, has, by law, greatly improved the status and efficiency of the medical officers of the army, navy and “Poor Law Medical Service;” has. by the Reg- istration Act of 1858, greatly repressed charla- tanism, and has notably stimulated medi- cal education, not only by this means, but also by • establishing boards independent of medical teachers to examine and grant diplo- and has by the four different Acts of of 1853, ’61, ’67 and ’71 forced “compulsory vaccination” on all infants over three months old; thus obviating the popular Anglo-Amer- ican outcry against invasions of the “per- sonal liberty of the subject.” But, surpass- ing in importance all these and other unmen- tioned laws, are the six public health Acts,} enacted from 1848 to 1875, which have estab- lished on a solid foundation an efficient sys- tem of public hygiene, with 15,000 sanitary dis- tThe British Medical Association was incor- porated in 1874. Its affairs are managed by a ' General Council.” composed of one delegate tor every twenty members, and the authority of this council is in large degree delegated to twenty members, who compose the “Committee of Council,” which meets not less than four times a year. tThe Public Health Act of 1848, the Nuisances Removal Act of 1855, the Local Government Act of 1858, the Sanitary Act of 1866. the Public Health Act of 1872, and the Public Health Act of August 21,1875. § See address on “Higher Med. Ed.,” etc., by Dr. Wm, Pepper. Philadelphia, 1877, (*) It is gladly announced that on March 14, 1879, North Carolina enacted a much improved board of health law, which is, however, still de- fective, specially as to an adequate appropria- tion. Annual Address before the tricts and the requisite number of sanitary officers. These Acts have rendered Great Britain pre-eminent in preventive medicine, and have secured to this great nation the preservation of its power and a constant in- crease to its prosperity. But, as science is ever progressing, so the British Medical As- sociation is constantly finding old structures to demolish, new edifices to erect. Among these it will soon demolish the coroner, build up inebriate asylums and other means to con- trol habitual drunkards; establish compul- sory revaccination at puberty, and erect for our envious admiration a few stately “Con- joint Medical Examining boards,” which will secure the people not only qualified phy- sicians but also competent midwives, phar- macists, dentists, and even professional nurses. With this imperfect statement of what has been, and will soon be accomplished by the British Medical Association, attention should be directed to the important advantages it en- joys over our American Medical Association. First, the small extent of Great Britian, the density of its population, the cheapness and quickness of travel, all tend greatly to facil- itate associated action. Secondly, the British medical profession has the inestima- ble advantage as to State Medicine, that it is able to concentrate its whole influence solely on one supreme legislative body—Parliment —while our form of government, since it, for the most part, reser ves to the states those pow- ers on which State Medicine depends, forces the American medical profession to fritter away its influence on forty-eight State and Teritorlal Legislatures. Hence, this import- ant lesson,that the American Medical Associa- tion is not so important to the American medical profession as the British Medical Association is to the British medical pro- fession; and that our thirty-seven State Medical Societies axe of in- finitely greater importance to our medi- cal profession than the thirty-one British Branch Associations are to their medical pro- fession. However, there are but few states in which the medical profession seems to realize these important facts, and even few State Medical Societies which seem to appre- ciate what is their chief function. For, if the promotion of State Medicine be not the para- mount object of a State Medical Society, then what is its chief object, and to whom else would it transfer the interests of State Medi- cine? Although some State Medical Societies seem oblivious to this duty, none the less the length of this address could be readily doubled in enumerating ail that has been and is being done by others of them. While the necessities of this occasion will not permit this, it is in- cumbent on me to prove that State Medicine has been and can be promoted in our own as well as in a foreign land by an organized medical profession. The first proof will be derived from the Massachusetts Medical Society, which num- bers in its membership much more than half the regular medical profession in the state, has one branch in every county, and more than one branch in several, has property valued at more than $30,000 and an annual income of about $7000. All that it has done need not be stated, for it wTill answer my purpose to re- call to you that it is in Massachusetts that are found the best State Board of Health, and the best Registration of Vital Statistics in any state, and the Medical Examiner occupy- ing the larger part of the coroner’s chair. If our society, even after many years, should succeed in only this much, then our society would merit the gratitude of the people, and would certainly receive the blessings of pos- terity. But since foreign and distant examples often cause conviction to abort, my last proof shall be derived from a state whose bound- aries kiss our own, and whose people are as like to us in virtues and in faults, and as be- loved by us as brothers—the State of Alabama. That a lesson by comparison may be profitable the comparison should be just. Then what advantage has Alabama over Louisiana ? The former enjoys, I believe, none over the latter except the following: In 1870 the one had 1418 practitioners of Medicine, the other 939; the one had 19% inhabitants to the square mile, the other 17%; the one neither had nor has a large proportion of its population crowded into one great city, thus diminishing the density of population in the country—the other had and has New Orleans; the one had 521,000 white population, the other had 362,000; the one had, in 1878,1802 miles of rail- road, the other had only 639; the one organized its first State Medical Society in 1848 and it lived until 1861. the other in 1849 and it lived only until 1856; and, finally, the Alabama society was reorganized in 1868 and the Louisiana society not until 1878. Of these advantages only one will be considered in re- plies to the question: What good use has been made by Alabama of the ten years (1808-’78) lost by Louisiana? The Alabama Medical Association deliber- ately considered for three years the construc- tion of a new constitution, which, pecular in several important particulars, specially pro- vided for the advancement of State Medicine; and it dates its success from the adoption of this constitution in 1873. It, at the same time, adopted, as guiding principles, that it would “never, under any circumstances, de- mand legislative action for the express and ex- clusive advantage of the medical profession,” and that it would maintain as a primary object the purification of the regular profes- sion itself, and as a secondary object, the suppression of irregulars; in addition, it seems to have appreciated the great neces- sity there is, that every scientific society should use the greatest caution in attempting to influence legislation on politcal, or per- so nal, or class matters, and on matters un- settled in science. The results which have followed are, that the Alabama society has organized thirty-two county societies, which have 382 members, and all of these are mem- bers of the State Society; in 1875 it secured from the Legislature ah Act,? which consti- tutes the State Society the State Board of Health and of Vital Statistics,and its affiliated county societies county boards of health; and in 1877, the Legislature empowered this so- ciety to appoint a State Board and county boards of Medical Examiners, and granted to these the extraordinary power to regulate, exclusively and regardless of all diplomas, the practice of medicine in Alabama, determining the qualifications .necessary therefor, subject to the sole restriction—that those proposing “to practice any irregular system of inedi- eine” should be authorized to practice, if found qualified in other branches than thera- Louisiana State Medical Society. 15 peutics. Thus, Alabama has formally recogniz- ed the supremacy of the regular medical pro- fession, subjecting irregulars to its super- vision ; and iu fact has, by the Acts of 1875 and 1877, constituted its State Medical Society a veritable medical legislature, as to both Medical Education and Public Hygiene, in- vesting this imperium in imperio with “great and unprecedented powers.” It is grievous to add that the legislators who la- bored thus well in the right direction failed to make any appropriation to pay the ex- penses indispensable to the execution of these laws; and it is very joyful to add to this, that the Legislature did in 1879 appropriate $3000. Who of you will not gain courage from Ala- bama’s example? Who of you will not earn- estly hope for the success ol this grand ex- periment in State Medicine ; and who of you will deny that I have now fully proved all I promised? But, if we are to pay “honor to him to whom honor is due,” then, in connection with the Alabama State Medical Association, must be mentioned the name of Dr. Jerome Cochran, of Mobile, to whom is due its con- stitution, and to whom is largely attributable the prosperty of the association and the conse- quent progress of State Medicine in Alabama. In conclusion, permit me, fellow-members, through you to call the attention of all physicians of our state to the many re- counted evils which are inflicted by ignorance and negligence of State Medicine and to the following considerations. As this society is not composed of visionary enthusiasts, we cannot indulge the extravagant hope that we can remove all these evils in a day, nor even in a generation. But, none the less, we can, in all soberness, hold these truths to be self- evident : that, as surely as this state keeps step with the march of civilization, so surely must these evils be eventually corrected; that a beginning must be made; that this beginning must be originated by the medical profession; and that an organized profession is the only agent competent to deal with these evils—which are relics of professional, as well as of public ignorance. The only remedy for this ignorance is in- struction by iecture and by publication which necessitate an expenditure of money, beyond the means of this society as of most others. But, if the medical profession were organized in county societies, these condensed into State Societies, and these aggregated into the American Medical Association; and if every physician cheerfully paid, as many now7 do, annual fees of from $10 to $15 t