The Present Condition, Prospects and Duties of the Medical Profession

Annual Oration 1841

By Edward Reynolds, M.D.

Gentlemen,

The return of another anniversary of the Massachusetts Medical Society, presents the usual causes of congratulation, in the harmony prevailing among its members, and the growing interest manifested in the pursuit of its important objects. United not for any private advantage, but for the advancement of medical education, and through it, the alleviation of human suffering, our periodical meetings are never unattended with pleasure or profit. Separated from each other over a wide extent of country, by the duties of a laborious profession, it is pleasant once a year to behold your familiar faces; to reciprocate the interchange of kind feelings; and to cheer each other on our arduous way. We can hardly assemble on these short occasions without some mutual advantage. If they do not make us much wiser, they always make us happier; for we never separate without some kinder feelings, and without acquiring some new interest in each other, as well as the noble cause to which we have consecrated our talents and our lives.

In conformity to the custom of the Society, the last hour of another meeting is to be devoted to the consideration of some subject connected with medicine and surgery. It would afford me more pleasure on this occasion to be the hearer, than the speaker. I invite your attention to a few thoughts upon the present condition, the future prospects, and the consequent duties of the medical profession.

Each age, like each individual, is marked by some features peculiar to itself. The history of medicine teaches the striking fact, that it has uniformly caught the prevailing spirit of each age; and successively transmitted in its own character, a faithful representation of the folly or wisdom with which it was associated.

Our age forms no exception to this fact. Its peculiarities have become impressed upon the medical profession; modified its pursuits, and changed its character, in conformity to itself, as in all former times. It has imparted to medical investigations a large portion of its own exactness; imbued them with a full measure of its philosophical spirit and abounding zeal; with a purer, bolder love of truth; an indisposition to reverence any opinions simply because they have grown venerable through age; a courage to prove all things, to take nothing on trust; to receive no opinion, and form no system which has not been submitted to the rigorous tests of observation and experiment; and a willingness to leave truth to work out its own way, in its own native strength, regardless of its result and its influence upon long-cherished theories.

It is a scientific spirit; the method of induction which has so long received the praise, but not the attention of philosophers,—that method for which Bacon receives all the credit, but of which, to the honor of medicine be it said, Hippocrates was the founder. The character of the age is eminently practical. All theory is regarded with more caution, and facts with more favor. The investigation of truth, less influenced by the imagination, is more under the direction of its only safe guides, observation, experience, the accurate cultivation of the senses, and rigorous analysis.

Such are the sources of the many valuable and splendid discoveries of modern science; discoveries, which constitute the chief ornament and the best boast of the age. Medicine and surgery, animated by the same improved spirit with which the sister sciences have been pursued, has kept an equal pace with them; and made more rapid advances than at any previous period, simply because a better philosophy prevails. It still represents, as in all other times, in its improved condition, the improvement of all other branches of knowledge. In the darkest ages, it has never fallen below the prevailing level of the sciences. It shuns no comparison with them in this its brightest age. At all times, it could boast of its Sydenhams, its Harveys, and other kindred minds, whose modes of seeking truth were perfect models, and whose contributions to knowledge are stamped with the seal of endurance. It now boasts of many, who, distinguished for great accuracy of observation, and extreme caution in deduction, have been as useful by the influence of their example upon the profession at large, as by their valuable additions to medical science.

The last half century forms the most remarkable era in medical science. It has effected more, perhaps, than all other periods in improving the profession, separating it from false theories, laying for it more sure and enduring foundations, and confining it within the sphere of those facts with which it is strictly connected, and which alone afford just views of the body in health and disease, and proper indications and modes of cure. The same general spirit of improvement which has marked the progress of all the sciences, and elevated some of them to such perfection, pervades every branch of medicine and surgery. The industrious observation of facts has produced a more prevalent love of truth; banished the blind adherence to system, which so long retarded their progress; diminished the disposition so natural to the mind to search after the wonderful: and secured more respect for plain common sense in all medical matters.

Its salutary results are seen in our systems of education; in the improved modes of teaching that prevail in our schools, both public and private; in the introduction of clinical instruction at our hospitals; the important changes that have taken place in the modes of studying disease, and in the opinions respecting it; and numerous discoveries in physiology and pathology highly creditable to the science, and of great benefit to mankind; discoveries, which, among the many uncertainties of the medical art, and the difficulties that oppose the seeker after medical truth, are highly gratifying; and may be regarded, at the same time, as the rich reward of philosophical investigation, and the prelude to still greater achievement.

Such are some of the general modifications imparted to the medical profession by the intellectual character of the period with which it is associated. It may not be an unprofitable use of the present hour, to take a cursory view of some of the acknowledged improvements which have resulted from it, and which constitute the true boast of modern medicine and surgery.

The present period is distinguished for a remarkable diffusion of anatomical knowledge. No other branch of medical science exhibits the onward impulse of the age so much as anatomy. Its industrious and successful cultivation in Europe, with the brilliant results that have followed, has invested it with an unusual interest, and awakened a new diligence every where in its pursuit. Minute anatomy, especially, has been prosecuted with extreme care; unravelled and described every organ of the body with great exactness. The aid of the microscope has revealed the nature and arrangement of some structures previously unknown; and so clearly established the value of extreme minuteness of anatomical investigation, and its practical application to the purposes of discovery, that its importance is now universally acknowledged. It is seen in some remarkable discoveries of great interest to science; and in the important physiological disclosures of which it is the foundation.

The diligent cultivation of general, especial and minute anatomy, forms a new era in the science. We are indebted to its zealous pursuit, for the extra ordinary number of new and valuable works, which, for extreme accuracy of description, minuteness of detail, beautiful illustrations of art, and their excellence and perfection, have superseded those of any anterior period. It is the source of the improved modes of studying, describing, viewing and teaching anatomy now prevalent in many schools; the increased amount of knowledge demanded of Professors by the wants of the student; in the zeal for patient dissection that prevails among teachers and pupils; the more general conviction of the necessity of abundant anatomical knowledge to medical or surgical eminence; and a corresponding willingness to labor for its acquisition.

The successful cultivation of comparative anatomy, the cherished offspring of modern science, may be regarded as another evidence of medical advancement. In the culture of its ample field, so rich in physiological treasures, the profession reaps an abundant harvest of knowledge. Its zealous pursuit, its adoption into the annual teachings of some of the best medical schools, and the deep interest it inspires, are sufficient proofs of its value. I need not remind this audience of the benefits thus conferred upon medical science, or the valuable truths thus added to physiology, by the Cuviers, the Bells, and others, who, in the pursuit of this interesting branch of study, have so admirably unfolded the philosophy of living structures, and the functions they are destined to perform; and so clearly illustrated the intimate connection between comparative anatomy and comparative physiology, and the anatomy and physiology of man. The general interest now manifested in the study of this noble science, so rich in the endless variety of its objects, and the sublime nature of the truths it unfolds, and the more comprehensive views of its paramount importance in the acquisition of physiological truth, are alike honorable to the learning and taste of the profession; and show, at the same time, an improved physiology, and a reasonable ground of expectation of future discovery in this delightful field of labor.

The diligent study of anatomy has given a great impulse to physiology as well as to medicine and surgery; stripped it of many false theories with which it was encumbered, and given it a more rational form and scientific character. The two sciences have always gone hand in hand together, mutually aiding and interpreting each other. Every advancing step in anatomy has been, at all times, the precursor of a corresponding improvement in physiology. Its unusual progress during the last quarter of a century, and the new fields, which, almost within that period, have been laid open for its investigation, may be regarded as the harbinger of a brighter day than has yet shone upon it.

An equally fertile source of pathological truth is discovered to the profession, in the extensive cultivation of pathological anatomy. This also is the offspring almost of modern times. A few years only have elapsed since this, now “the fairest province in the land of science, was a barren and uncultivated waste;” or explored only by an occasional traveller, like Morgagni, who, in the riches gleaned from it, first made known its inexhaustible treasures. It has since been assiduously cultivated by many laborers; among whom may be mentioned with especial respect, Bichat, Baillie, Louis, Andral, Hunter, Bouillaud, Rayer, Carswell, Cruveilhier, Meckel; to whom, I perhaps may be permitted to add, in this place, our own Jackson,—who are all endeared to every lover of science, by the valuable additions they have made to it. Their writings and museums will long outlive the perishable monuments that surviving friendship may erect to their memories.

We are greatly indebted to these individuals for a great amount of positive knowledge respecting the changes effected by disease, never possessed before, for the rectification of many errors, grown venerable by age, for an improved diagnosis, the subversion of many false systems which have prevailed to the disgrace of science, a great advance and improvement of the art; and though last, not least, to the spirit of philosophical inquiry, the present guiding spirit of medical study, which, whether we compare the present with the past, or look beyond the present to the future, fills us with hope and expectation.

Morbid anatomy may be regarded as one of the essential supports of the medical edifice; the chief corner-stone, upon which it may repose in security. All its teachings are facts, destined to assume a permanent place in the science. Already it has greatly improved the whole domain of medicine and surgery, and led the way to results which are a just source of professional pride, and a pleasing assurance of still higher advances towards the perfection of the art.

The astonishing progress of chemistry, is another triumph of modern times. Its application to physiology has done something to increase our knowledge, and the future prosecution of its exact labors affords the promise of more. Its application to pathology has corrected some errors, revealed some interesting truths, and suggested several therapeutic agents, of great value in the relief of disease. It is so intimately allied to the medical science, that its rapid progress cannot be regarded without deep interest, and the belief that physiology, pathology and therapeutics may look to its future discoveries for some material aid in their advance to improvement.

In enumerating the improvements of medicine, intimately connected with the above pursuits, the first place should be given to the discovery of auscultation; for which we are indebted to the immortal Laennec, who first detected the murmur of respiration, and the several modifications it undergoes during the diseases of the chest; a discovery making us better acquainted with the physical alterations of the lungs and heart, by rendering their physical effects sensible, and second in importance to none within the whole range of medical investigation; scattering the obscurity that always rests upon this important class of diseases, to the mere observer of symptoms, and affording in many instances certainty for doubt, and the assurance of science for the doubtful suggestions of the imagination.

The science of auscultation, based as it is upon fact, experience and observation, demonstrated by the unerring results of morbid anatomy, and having truth for its foundation, has survived the reproaches of ignorance, and the various forms of opposition it was destined to encounter at its first announcement, and gradually secured the attention and respect of physicians, until its claims are universally acknowledged. No man now claims the character of an accomplished physician, who neglects its cultivation. Assiduously studied during the last twenty-five years, it has attained a great degree of perfection, and is justly regarded as the greatest triumph of modern medicine.

By the aid of this splendid discovery, the well-educated pupil is qualified to distinguish thoracic diseases, with an accuracy that would have surprised the veterans of former days; to detect them in their incipient forms; to trace their origin, amid groups of symptoms calculated to mislead the mind, to their unsuspected source; to separate curable and incurable cases; and to act in all cases with a degree of wisdom, and occasionally with an energy, that uncertainty never secures.

But a discussion of the merits of this invaluable discovery, and the various ways in which it proves a solace to the physician, and a blessing to the sick, is obviously unfitting to the present occasion. Your own experience affords a sufficient test of its value. Your voluntary tribute of gratitude to the discoverer, is the best evidence of its claims to your respect and regard.

The thoracic cavity is not the only region which has been illumined by morbid anatomy; nor are its diseases the only affections which have put on the definite, enduring forms, with which science always invests the objects of its legitimate research. It has penetrated every region of the body; and revealed many important facts respecting their obscure diseases, that will always rank among the certain things of medicine; as the connection of typhus with a diseased state of the mucous membrane, especially the mucous glands of the bowels,—at all events, the more frequent concomitance of gastro-intestinal inflammation, whether it be a cause or an effect, than any other lesion. The same guide also exhibits the occasional connection of typhus with pneumonia, inflammation of the veins, and other lesions of other organs. It teaches, also, the fact, that from the commencement, it is sometimes an alteration of the blood, without any appreciable lesion following the introduction of poisons and miasmata into the system.

There is much in this, and all disease, which the Creator has veiled from the penetrating gaze of human curiosity. While the destiny of man remains unchanged, this veil will never be wholly withdrawn; and the physician will be left, as now, to the humble office of a faithful observer, and a diligent recorder of facts. Facts must ever constitute his main strength. If they do not teach all things, they daily teach much that is useful and satisfactory. If we are not able to cure diseases better than our fathers, we have more definite and philosophic notions respecting them. It is something, to have escaped from the dominion of their unscientific nosographies; to hear less of inflammatory, bilious, nervous and putrid fevers; and perhaps to commit less frequent errors in practice, under the sanction of a name; to have learnt, though the lesson is taught by the triumphs of death, that the typhoid state may be developed by a number of causes wholly different from each other; to understand, when Pneumonia or Phlebitis is its base, why its course is so rapid; when the intestinal follicles is the accompanying lesion, why it is so slow; that their ultimate seat is identical, though their origins may differ, and to comprehend the reason of their varieties, in the various causes that have produced it.

The diligent pursuit of the same means has added many other important facts to our knowledge; as the inflammatory nature of acute rheumatism, and its almost invariable co-existence with Pericarditis and Endo-Carditis. It has accumulated a rich treasury of facts in the various diseases of the brain and its membranes, and other portions of the nervous system; which relieve us of much painful uncertainty, even when our therapeutic agents are inoperative, and enable us to enjoy the pleasures of science while suffering the sorrows of unsuccessful efforts to save life.

Many valuable contributions have been made to our knowledge of the diseases of the urinary organs. The recent discoveries in animal chemistry, and the investigations of morbid anatomy, under the scientific labors of Bostock, Brodie, Prout, Bright, and others, have revealed many positive facts hitherto unknown, which cannot fail to improve the diagnosis and treatment of these difficult and insidious affections.

Such are some of the changes effected by the progress of medical science. Time forbids a further enumeration, which might with propriety be extended over the whole domain of medicine; for all diseases have submitted more or less to the revolutionary hand of modern improvement. The result, in a word, is every where more correct opinions respecting the origin, the seats, and the effects of disease, an improved diagnosis of all disease. The diagnosis of one, and that perhaps the most important class of diseases, has attained a degree of perfection that leaves little or nothing to be desired.

The modifications of Therapeutics, under the searching observation of modern science, are neither few nor unimportant. The application of the same philosophic spirit to Therapeutics, under which the other branches of medicine have attained their present improved condition, has taught a better appreciation of the powers of nature, or that interior force, which, presiding over all the phenomena of life, is continually combating the tendencies of physical and chemical laws, and constantly striving to maintain the body in a condition of health, and to restore it in disease; a more accurate knowledge of the tendencies of all diseases to health, or to destruction; and the means best calculated to favor or combat these tendencies; the discovery of the fact, that no medicine is capable of curing any disease by its own, individual power; and that it effects a restoration to health in all disease, only in proportion as it may favor the action of nature in her restorative efforts; and a more abiding conviction, that nature is capable of curing many diseases, under a proper dietetic system, without the aid of medicine,—of which we have abundant evidence in the confiding trust of the scientific physician, and the harmless fooleries of the disciples of Hahnneman. These simple truths may be said to form the groundwork of the therapeutic revolutions of modern medicine.

Therapeutics, in less enlightened ages considered the easiest, is now known to be the most difficult branch of the medical profession; demanding, in its advance to certainty, a spirit of observation, a soundness of judgment, and a freedom from preconceived opinion, that fall to the lot of few individuals; a mind thoroughly imbued with pathological knowledge; capable of appreciating disease, anticipating its character and tendencies, and judging accurately under every combination of circumstances, when the safety of the patient depends on a prudent trust to the operations of nature, or an active recourse to medical treatment. John Hunter used to say, “I have hope of the profession, because physicians have ceased to know all things.” A better knowledge of the difficulties to be encountered, may be regarded as one of the improvements in Therapeutics, and the first necessary step to a victory of them.

It cannot be pretended, that the advances of practical medicine have been equal to the discoveries in its elementary branches. Our progress consists less in an increased power of curing disease, than in a more accurate knowledge of its causes, nature, relations and tendencies. And yet, the remarkable modifications of modern Therapeutics exhibit, amid all the obvious difficulties that invest the subject, a marked superiority in all that relates to the prevention of disease, the comfort of the patient during its continuance, and his safety; both in those cases which may be confided to nature's unaided efforts, and those requiring the energetic interference of art. This superiority is seen in the greater simplicity of its means, the introduction of some very valuable medicines, a better knowledge of the operation of all medicines, and the true share which they take in the cure. The change is not one which diminishes our confidence in medicine. On the contrary, our belief in its utility is increased. With an expurgated pharmacopœia, a diminished array of specifics, a more rational, though less confident trust in the specific power of medicine, and the conviction, that in some cases it is useless, in others, injurious, and in others, judiciously applied, absolutely necessary to save life; it is more worthy of regard, because conjoined to a better understanding of disease, more rational views of the action of medicine, and an enlightened confidence in the powers of nature; it conduces with so much more certainty to the comfort of the sick, and the relief and cure of disease.

It would not be an unreasonable expectation, that the extension of medical light to the community should abate the prevalence of medical folly, except for the fact, that the fountains of human credulity, flowing on in undiminished fulness for six thousand years, are evidently inexhaustible. Each periodical advancement of the art has been attended with a corresponding paroxysm of abounding faith in systems remarkable for nothing so much as their absurdity. It is just so now. The present period is equally noted for medical improvement and medical folly. The noblest era of the science proves the most balmy day of medical pretension, in all its forms, from the devices of the host who attempt to practice the art without learning the science, to the various so called systems, which, emanating from the profession itself, present their claims to the notice of a believing community.

The most remarkable of these, at present, is Homeopathy, a system, if it deserves the name, “which sets aside all former observation; contradicts all former experience; upsets not only all theory, but all facts; declares war against the inductive science; and acknowledges no organic alterations;” which sees in all diseases, only the immaterial changes of a spiritual principle, and in all remedies, only the result of spiritual forces.

A system which gravely tells us that diseases and their causes are not material, but merely immaterial changes in ourselves; that there is nothing in them mechanical or chemical; that they do not depend on a morbid, material principle, but are only partial alterations of spiritual, or, as Hahnneman sometimes calls it, synonymously, dynamic life. That it is by the observance of symptoms alone, that the physician, however sharp-sighted he may be, can learn any thing of the nature, character or treatment of disease.

That the worst species of chronic diseases, and the most incurable, even by Homeopathic means, are all produced by the heroic remedies of unskillful Allopathic physicians.

That the only real, fundamental and productive cause of all “proper or natural chronic diseases” (all such as are not produced by Allopathy), such as the numberless forms ranging under the name of nervous weakness, hysteria, hypochondriasis, imbecility, mania, melancholy, epilepsy, spasms of all kinds, rickets, caries, cancer, fungus hæmatodes, gout, hæmorrhoids, jaundice, dropsy, amenorrhœa, hæmorrhage from the stomach, nose, lungs, bladder or uterus, asthma, abscess of the lungs, sterility, deafness, cataract, gravel, paralysis, lameness, and pains of a thousand kinds, is nothing more or less than the itch. And that all others, not falling within the legitimate sphere of this great productive cause, are generated by the miasma of syphilis or sycosis.

That the only mode of curing any of these, is by the administration of infinitessimal doses of some agent, which given in health would produce the disease. That these doses, to be effectual, must be infinitessimal,—the more so the better,—at all events, as infinitessimal as the millionth or the decillionth part of a grain. Nay, even the aura continually streaming from one of the little sugar granules, weighing only the hundredth part of a grain, and contained in the tiny Homeopathic bottles, where it has been drying twenty years, will retain all its strength during that long period, provided the bottle has not been uncorked for use oftener than 1000 times, and snuffed up into the nostrils; or, if the patient has a catarrh or a polypus, breathed through the lips, it will be found as powerful as the real Homeopathic granule itself; cure disease not only quicker but in a more gentle manner, and, carried in the pocket ready for use on all occasions, will relieve the patient of all need both of druggist and doctor, for the remainder of his days.

That the active properties of all medicines become developed in proportion to the minuteness of the dose, and the friction or shock communicated by the number of shakes given to the vessel in which they have been dissolved, if they are to be prepared in a liquid form; and the amount of rubbing in the glass mortar, to which they are subjected when destined to assume a solid form. Such is the mighty influence of the shakes, and the friction thus communicated to medicine, that the cautious author of the system kindly warns us, in their preparation, never to exceed ten energetic shakes, from above downwards (Schüttel Schläge) in the former case, and the period of one hour in the latter, lest it should develop the inherent virtues of medicine to an alarming extent. Indeed, he cautions his brother Homeopaths against the dangerous shaking of the medicine ever after, if unwittingly carried about in their pockets, while visiting their patients; attributes their former ignorance of this fact to a want of accurate observation; and assures us, that a more abundant experience, and a closer observation, have at last taught him, that to obtain the necessary power locked up in a drop containing the millionth or the decillionth part of a grain of medicine, two shakes are actually as good, and even safer than ten,—of the truth of which we have no manner of doubt.

Such are the chief elements of Homeopathy, or the “transcendental reverie of a German charlatan,” as gathered from the peculiar and uncommon dialect of the Organon; which, unequalled in folly by the wildest ravings of Paracelsus, lays its bold claim to favor, as the last, the best, and the ultimate point of medical perfection.

Its progress is only another evidence of the extreme credulity in medical matters that has formed the feature of every age; the morbid love of the marvellous, which characterizes a certain portion of every community by no means the least informed; the slowness with which medical knowledge finds its way to the public mind; and the readiness with which the sick seize upon any system however absurd, which, like this, has expunged the word incurable from its vocabulary. It has been forty years travelling from the obscure place of its birth to our transatlantic shores. It is probably destined, like Mesmerism, and all other kindred species of medical humbuggery, to have its run; and after, in its turn, heaping another full measure of ridicule upon the healing art, to transmit, at its death, as a compensation for the temporary injury inflicted upon a noble profession, more abundant proofs of the successful manner in which nature triumphs, under a regulated diet, over many diseases, without the help of art. From a careful observation of human nature, we have long since ceased to wonder at any credulity of the sick, however great its amount or its absurdity. But that any well-educated physician of the present day should be found among the believers or the propagators of such “mystical nonsense,” excites our surprise, and must form an apology for occupying the attention of this practical audience with it.

Surgery, during the last thirty years, has reached a high degree of perfection. From the time of John Hunter to the present day, it has been advancing with extraordinary rapidity; laying its foundations more and more deep in healthy and morbid anatomy; continually strengthening its connections with medicine; enriching itself with pure, pathological principles; and thereby augmenting its curative power; extending its boundaries, and strengthening its claims to the dignity of a science. The nature of inflammation, the character and tendencies of its various terminations, the constitutional causes that modify its action, when acute, chronic, scrofulous, peculiar or specific, are better understood and more fully appreciated. Whence the various improvements in the treatment of wounds, whether the result of accident or the surgeon's knife, the application of ligatures, the management of fractures, simple and compound, now more or less familiar to the least observing, and so conducive to a safe and speedy cure; and not unfrequently the cause of saving not only a limb, but a life, which in former days would have been sacrificed to the prevailing ignorance of the simple principles, which first originated in the great mind of John Hunter, and have since become the common property of every well-educated physician and surgeon.

A comparison of modern surgery with that of any former period of its history, is highly creditable to the industry and talent of its present cultivators. Every department of the science has felt the influence of the pure principles with which it has become associated. It may be seen in the improved modes of surgical education, the increased amount of knowledge required for its pursuit, the more scientific character of its writings, the improved diagnosis, and the more definite distinction between those diseases that are amenable to internal, and those which demand the aid of mechanical, remedies; between those which yield to a judicious combination of both, and those which present a malignancy that resists all remedies.

The perfection of modern operative surgery is at once the evidence of superior attainment in anatomy, and the ingenious and fearless spirit of the cultivators of this mechanical branch of the profession. The ingenuity of its devices, and the consummate skill of its execution, have never been equalled, and will probably never be surpassed. Confident in the possession of perfect anatomical knowledge, it has overleaped the barriers apparently set up by nature to its encroachments; successfully pushed its way onwards to the performance of almost miraculous feats; and shown that nothing is too delicate or too difficult to resist the efforts of its daring skill. Operative surgery has, perhaps, attained its highest point of attainment; and leaves few laurels for its future votaries, except for discoveries, which, in the progress of improvement, may, like Lithotrity, mitigate the sufferings and diminish the dangers of surgical operations, or serve as substitutes for them.

This is all well. It adds another source of confidence in our noble profession, by the assurance, that when the condition of the constitution and the character of the disease present no obstacle to the operator, the patient may submit without fear to any effort of mechanical skill.

But surgery now boasts of a better triumph, in a diminished fondness for surgical operations among well-informed members of the profession; in a growing love of medical knowledge, an improved pathology, a more skilful diagnosis, and a better treatment of disease. From the days of John Hunter, who laid the first foundations of medical surgery, there has been a constant increase of knowledge among surgeons; a more intimate blending of the different branches of science, and a consequent diminishing love of operative surgery. The distinction between curable and incurable disease, between those cases which are capable of yielding to medical, and those which must be abandoned to mechanical treatment, is better defined. The successful cultivation of anatomy, physiology and pathology,—the peculiar professional feature of the age,—rescues a multitude of cases from the domain of mechanical, and transfers them to the curative efforts of medical surgery. The records of public and private practice exhibit a marked diminution of operations. Under the searching investigations of modern experience, the pruning-knife has been applied to surgery, as well as to medicine. Enlightened by its accurate teachings, and warned by its numerical tables, the excision of the female breast, the testicles, and other glands and parts affected with cancerous and fungoid disease, has become less frequent. A more scientific, protracted, constitutional treatment, and a more confiding trust in nature precedes the amputation of a limb. The operation of trephining, in injuries of the head, is comparatively a rare occurrence. While we fully appreciate the merits, and admire the skill, of all necessary operations, and pay the grateful tribute of respect to the performers, the kindlier feelings of nature rise up against all which are unnecessary; and especially those which are undertaken as much for the fame of the operator, as the chance benefit of the patient; of which the records of surgery in all times, past and present, exhibit too many examples. The voice of science, as well as of nature, is now able to utter her disapprobation on all such occasions.

A view of the present condition of surgery, with its diminished taste for operations, its philosophic modes of treatment, so much simplified and improved, and its favorable results, as evinced in the various injuries of the head, the management of hernia, scrofula, compound dislocations, simple and compound fracture, aneurism,—indeed, of all external diseases,—is highly creditable to the professional head and heart. It shows the great superiority of medical to mechanical surgery, and the extent to which a more enlightened pathology has elevated the science.

The domain of operative surgery has been materially extended, by the addition of several new branches. The investigations of Stroymeyer have enriched it with Tenotomy, which, from the simplicity of its manœuvres, and its easy application to many species of distressing deformity, may be regarded as one of its beautiful triumphs. It affords another proof of the intimate connection of anatomical research with the advancement of surgery, as well as medicine. We are indebted to morbid anatomy for the development of the unnatural condition of the joints and muscles, which first led the way to this invaluable discovery, as it has to almost every other in surgery.

Surgeons of all countries have now applied it to the numerous species of deformity originating in unnatural muscular contraction, with an amount of success as gratifying as it is useful. Its easy adaptation to the several varieties of club foot, contracted joints, torticollis and strabismus, has been almost uniformly successful, and promises materially to diminish this class of affections. The simplicity of the discovery excites our wonder that it was so long unknown; its extensive utility calls forth our gratitude to the discoverer, and our pride in an art so rich in blessings to mankind.

Plastic surgery, so successful in repairing other kinds of deformity, and certain cases of distressing disease, is another, and no mean or unimportant, addition to the art. Though not of recent origin, it has been much perfected by the talent of modern operators. It is certainly a source of gratification, that surgery, whose office has so long been that of taking away parts of the body, has at last learnt the science of forming them anew; that, having been so long a notorious scar-maker, she has now become a great scar-mender. We hail the return of the Taliacotian art, after its slumber of ages, back to the profession. We never see a new nose skillfully replaced, a new lip transplanted from beneath the chin, or a new eyelid neatly formed from the temple, without a feeling of pleasure, greater than can be produced by the removal of a limb, however skillfully executed, or the excision of a breast, however adroitly performed.

The last thirty years have been noted for the successful cultivation of opthalmic surgery. It is within the memory of some who hear me, when the interesting diseases of the eyes were wholly neglected in this country, or the object of attention to a number so limited, as to be incapable of proving extensively useful to the profession or the community. Its adoption into the profession may be regarded as another valuable addition to the science. The establishment of public Eye Infirmaries, where a wide field of observation is thrown open to the pupil, is eminently calculated to advance the study of pathology. Perhaps no other organ is so well adapted to the purposes of pathological observation as the eye. It presents, in its compound structure, a perfect specimen of all the tissues of the body, and, consequently, a perfect example of all its diseases. Its beautiful transparency enables us to watch the progress of morbid action with great accuracy; to discern all the modifications and consequences of inflammation in the various tissues (of course, the same in the eye as in all other parts which are concealed from view), and the effects of remedial agents; and renders it obviously one of the most easy and beautiful objects of medical study.

Our public opthalmic institutions annually send forth a large number of pupils laden with the rich fruits of an ample experience, and the abundant ability of extensive usefulness. A general interest is awakened in the investigation of the diseases of the eyes. Opthalmic surgery is beginning to be considered a necessary branch of medical education. The time is not distant, when its high claims will be generally acknowledged here, as in Europe, by every well-educated physician. Its rich soil, so successfully cultivated by some of the most eminent pathologists, cannot be examined without a valuable harvest to all future laborers, who found their expectations of medical success on accurate pathological knowledge.

The diseases of the ear, almost wholly neglected from the time of Hippocrates to the present day, have been carefully studied of late years. A minute study of the anatomy, structure and functions of the organ, has at last thrown some light upon its obscure affections; discovered in its middle chamber some causes of deafness previously unknown; and in the application of appropriate remedies, by the Eustachian tube, it holds out some slight hope of success in the management of a portion of its hitherto abandoned and uncomprehended diseases. A more careful dissection of the internal ear, in cases of congenital deafness, reveals some morbid changes not known before; and has added a few facts to our knowledge, if it has not increased our ability of relieving these unfortunate cases. The observations of Kramer, Delau, Itard, and others, enable us to classify the diseases of the ear; to distinguish those of the external, middle and internal chambers with tolerable accuracy; to separate incurable from curable cases; and to regulate the treatment of the latter upon more scientific principles.

A knowledge of the morbid changes of the ear, from the difficulties attending their dissection, and the small number of cases presented for inspection, is necessarily very imperfect; and will probably, for a long time, continue to be so. It is probable, that future discoveries may increase the number of facts, without materially advancing the success of curative means. Aural surgery is, on the whole, much less satisfactory in its results, than the amount of knowledge already acquired, and the writings of its cultivators have induced us to expect. It is, notwithstanding, capable of relieving a considerable amount of disease; and may be considered, in its present improved condition, an important addition to surgical science.

These contributions to modern surgery are, of themselves, abundant evidence of its progress. But there is no part of her wide domain unmarked by the hand of improvement; no class of her many diseases, which does not exhibit proofs of more accurate knowledge, and more simple, more ingenious, and more efficient remedial agents. Wherever we turn, we find a more enlightened pathology, and, as a natural consequence, the discovery either of new modes of treatment, or a more judicious and scientific application of those already known.

The diseases of the joints have been classified, under the light of anatomy, according to the several textures entering into the composition of these organs; their diagnostic marks settled with great accuracy; and their treatment determined upon philosophical principles, and in strict accordance with their pathological conditions. The vague ideas formerly attached to the terms, white swellings and scrofulous joints, without any well defined meaning, and indiscriminately applied to all the diseases of the joints, were, at the same time, the convenient cover of ignorance, and a prolific source of gross and fatal errors in practice.

The obscurity in which these difficult and insidious affections were formerly involved, has vanished under the clear light of anatomy, and the careful inquiries of science. Inflammation of the synovial membrane, with all its varieties and consequences—ulceration of the articular cartilages, with all their causes and dreadful results—scrofulous disease, with its constant peculiarities—and the malignant affections of the joints, are the names of things now clearly understood, and each the subject of treatment, simple, scientific, and more successful than at any former time. The pathology of all these maladies, now well known to all who have studied the subject, either in the admirable writings of Brodie, or by following the strictly inductive path opened by him for their investigation, constitute, at the same time, a splendid evidence of the value of anatomy in its application to medical study, and one of the most satisfactory improvements of surgery.

The investigation of the diseases of the rectum, which rank among the most annoying affections of the body, has been followed by the most satisfactory results. The nature of hæmorrhoidal tumors, prolapsus, fissure, stricture, blind sinus, polypi, and some others, is now well understood; their symptoms so clearly defined, that the diagnosis is easy, and the principle of cure manifest. Their treatment is distinguished by improvements, as simple in the application, as they are successful in the relief of disease.

The pathology of the glandular system is greatly improved. The great confusion formerly resting upon the diseases of the breast and testicles, has passed away: The well-educated pupil is now able to discriminate them, under the various modifications presented by the action of inflammation, in its several varieties; to treat them with skill, and decide when they are the subject of medical, and when of surgical aid. The progress of pathology is marked by corresponding evidences of improvement in the diseases of the osseous system, the urinary organs, the specific inflammations, and, indeed, in every department of surgery. It would exhaust your patience, to speak of the improvements in the treatment of wounds and fractures, the cold water dressings, and the immoveable bandage, and the many changes in the treatment of disease, which result from the observation and experience of modern surgery. The present occasion is obviously insufficient for the simple enumeration of the various additions to surgical pathology and therapeutics, which would singly form an ample and a useful topic of discussion. This general view suffices to show, that the present falls behind no other age in a diligent use of opportunity; and that it has perhaps made a more valuable progress than any other, since all the means of its advancement are calculated by the anatomical character of its researches, and the statistical nature of its observations, to give a greater degree of exactness both to medicine and surgery; and to found the science on truths more certain of endurance, because of a more positive character.

Another, and a most pleasing evidence of medical advancement, is the improved condition of professional feeling, the urbanity of manners, the courtesy, the kindness, the respect for the rights, the reputation and the acquirements of each other, which exist among us, and which generally characterize the members of this large society; the marked diminution of the little jealousies, the anger, and the evil speaking that, in almost all other places, and all other times, have been the reproach of the medical profession; but which this Society and the Boston Medical Association have done more, perhaps, than has been effected in any other community in the world, to wipe away from her otherwise fair escutcheon. It is seen in the harmony that prevails for the most part in our public counsels, and in our more private walk with each other; and in the increased respect with which we are consequently regarded by an intelligent community. This is partly the result of the excellent regulations and the praiseworthy designs of this Society. It is also the evidence of a higher condition of medical attainment; an indirect proof of a more scientific pursuit of medical truth; the existence of a more fixed standard of medical reputation; and a more extended conviction that the surest path to enduring medical fame is the acquisition of accurate knowledge in anatomy, physiology and pathology, and the cultivation of the kind, honorable dispositions that generally characterize the truly scientific man.

It appears, then, that the abounding zeal and talent of the profession have greatly advanced the condition of its elementary branches. The extended cultivation of these has laid the foundation of a more accurate knowledge of disease; and led the way to many improvements in the practice both of medicine and surgery; to discoveries of great value; the addition of several new branches of surgery; improved modes of study, and an elevated moral and intellectual professional standard.

The study of morbid anatomy, especially, has given a precision to diagnosis unknown before; and otherwise elevated the science, by basing it upon the positive truths of pathology; thereby rendering it more permanent, and less liable to be subverted by the progress of future discovery. But it still remains an unfinished work. Anatomy and physiology are certain guides to many of the truths of pathology; but not to all of them, since there are many diseases, of which these sciences teach but little; some, of which they teach nothing; and a large proportion, in which they express only the organic consequences of morbid phenomena, which are still unexplained.

Practical medicine, therefore, has not advanced in the same degree as its elementary branches. However valuable the latter have been in giving exactness to the science, and correcting many of its errors, they still leave us,—in the great practical business of the physician—studying the character of disease during life; recognizing its phenomena before they have produced fatal changes of structure; and applying the successful means of cure,—but little if at all advanced beyond the judicious, practical observers of all ages.

The great aim, therefore, of our future labors is, to render an exact knowledge of pathology more subservient to the benefit of man, in learning the causes, and in the prevention and removal of the many diseases of which he is the heir. Perfect attainment in medicine is impossible. The decree of Heaven, which writes man mortal, and the complicated and difficult nature of the inquiry, forbid even the hope of this. The facts of medicine being living phenomena, and constantly influenced and modified by a thousand agencies beyond our control, are more difficult to be seized, and correctly analyzed, than the fixed, definite objects of other sciences. Extensive knowledge, accurate observation, great soundness of judgment, and a comprehensive view of the mutual relations of all the branches of medical study, are necessary to afford security against constant deception in the formation of correct opinions, especially in regard to the efficacy or inefficacy of remedial agents.

The retrospect of the past, however, is encouraging. While the inherent difficulties of the science tend to moderate expectation, its recent progress encourages a hope that the accurate observation, and the improved reasoning powers of its future master-spirits, may, although it must ever stop short of full attainment, excel us as much in the practical application of pathology to the cure of disease, as we have our predecessors in the condition of its elementary branches. Something may be expected from the continued cultivation of these. Statistical medicine, when its more universal application shall have corrected the errors of incompetent observation, will doubtless give greater precision to the study of medical facts, and advance the knowledge of therapeutics in common with all the other branches of the profession. The recent labors of physicians have been in the prosecution of those studies that tend to render medicine exact. The remaining labors will be those that tend to render it practical. The success that may crown this more difficult task, lies concealed in the future. Whatever be its amount, we doubt not, that it will be equally honorable to the progress of the human intellect, and in the highest degree conducive to the welfare of man.

The elevated standard of the medical profession, while it gratifies pride, and animates hope, imposes upon all its followers duties and obligations of no ordinary importance. It evidently demands more knowledge than at any previous period; and should stimulate us to an industrious pursuit of the various sciences on which it is based; a more ardent love of the science; and a stronger interest in its welfare and progress; a more careful cultivation of the observing and reasoning faculties, diligent study and extensive reading, that we may keep pace with the constantly increasing information and discoveries of the day.

The fields of anatomy are not yet exhausted. The hand of diligence will bring forth many treasures that yet lie concealed beneath the surface of its much cultivated ground. Much as morbid anatomy has already done in giving exactness to medicine, unravelling the processes, and explaining the history of disease; and teaching the physician and surgeon the true ground, both of their hopes and fears, and the proper direction of remedies; it is destined, in the hands of its future cultivators, to secure still greater triumphs, both in the knowledge and the treatment of disease. It should be pursued, therefore, with a diligent, but not with an exclusive spirit; remembering that it unfolds only a portion of the hidden things of pathology, and reveals only the incurable states of certain diseases, and little or nothing of many functional disorders, which constitute a large portion of the daily business of the medical practitioner. A knowledge of these can only be derived from a faithful study of disease in the living body. Each should receive its due consideration.

The treatment of disease, until a better knowledge is obtained, must be found in a rational empyricism, based on the result of the observation of all times. The cultivation of modern medicine is not without its faults. We do not study disease in the dead body too much; but we study it in the living body too little. In the pride of more recent discovery, the merits of our predecessors are perhaps not sufficiently valued. In throwing off their consecrated errors, we may have swept away some of their valuable truths. The human mind always tends to extremes. A certain amount of skepticism emanating from high places in the profession, has propagated its contagion to a considerable extent; and may be as injurious, in some respects, to the interests of the science, as the empyricism or the dogmatism of former days.

While we concentrate the light of the exact sciences upon disease, and strive to excel those who have gone before us, in a faithful observation of the living body, correct analysis, and accurate deduction, we shall perhaps advance the interests of the profession more by a rational confidence in remedies sanctioned by the experience of all times, whether we understand their action or not, than by the indulgence of a skepticism that is not always harmless because it is fashionable; or a vanity which blinds us to the fact, that no age in medicine has been without its accurate observers; and that our age, however brilliant in discovery, is indebted for much that is invaluable in practical medicine, to the wisdom and experience of those who have preceded us in all ages.

Since our last annual meeting, Sir Astley Cooper, the most distinguished honorary member of this Society, after having done more for the advancement of surgery than any other man since the days of John Hunter, has paid the debt of nature, and gone down to the grave full of years and honor. Those of us who were favored with his acquaintance, will ever bear his unsolicited kindness in affectionate recollection; and pay the tribute of our unqualified admiration to his wise teachings. England claims the honor of his birth. His well-earned fame is the cherished treasure of a grateful world.

Dr. Thomas Miner, another honorary member, well known by his contributions to medicine, and his various learning, adds another to our list of departed brethren. It is our painful duty to record the death of Doctors Silas Allen, James Holland, Uriah Hagar, and Nathaniel Swift, who, having faithfully served their day and generation, are gathered to the fathers,—all of them in a good old age; the eldest having attained the term of 78, and the youngest 62 years.

It is somewhat remarkable, that in a Society composed of nearly 800 members, so few should have died in the space of a year; and that each of these should have left, in the number of his years, so satisfactory a testimony to the healthfulness of the medical profession. Our necroscopic records present an annual evidence of the limited power of medicine; and a motive urging us to diligence in the use of the rapid period allotted to each of us for the advancement of our useful, though difficult science.

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