Massachusetts Medical Society: Medical Societies: Their Organization and the Nature of Their Work

Medical Societies: Their Organization and the Nature of Their Work

Annual Oration 1881

By J. Collins Warren, M.D.

“This may be considered the birthday of medical honors in America,” wrote the Provost of the University of Pennsylvania, in recording the first medical commencement held in its college hall on June 21, 1768, and the occasion did mark the beginning of a new era for medicine. Two years before, a State Medical Society had been formed in New Jersey, but with this and one or two trivial exceptions, no attempt had been made to organize or instruct medical men on this side of the Atlantic. Previous to this period, those who desired a medical diploma were obliged to seek it in the mother country; but out of the three thousand physicians then in practice, it has been estimated that not over four hundred had received the degree of M. D. from a medical college. Many of the practitioners of medicine were also clergymen, taking charge of the bodies as well as the souls of their patients.

But the incubation period of two centuries was nearly over, and the work of organization and teaching had already begun. All classes in society were beginning to feel the quickening influence of the infant republic, which was soon to be added to the family of nations. In New England we were less fortunate than elsewhere; the means of obtaining a knowledge of medicine were more limited and deficient than in the middle and southern provinces; but with the Revolutionary War came a demand for medical services, out of all proportion to that which had previously existed, while the establishment of military hospitals afforded an opportunity to study disease. As the tide of battle swept towards the South and the period of war was drawing to a close, the new order of things began to shape itself in this part of the country. The military combinations, which finally culminated in the surrender of Cornwallis, were already in course of development, and the final scenes of the military drama were rapidly following each other, when medical science in this State first crystallized into definite form.

The Massachusetts Medical Society was organized by the better educated portion of the physicians of the State, for the purpose of establishing a standard of education in the midst of the then existing chaos. No system of medical education had previously been observed in the State, and no means whatever existed of ascertaining the qualifications of candidates for the profession. A young man might pursue his studies in such a manner and for such a length of time as he saw fit, and then enter upon practice without examination or license of any kind. It necessarily followed from such a state of things, that a considerable number came into the profession who were altogether unqualified for its high responsibilities. Every new practitioner was an object of suspicion. The original plan contemplated the organization of an examining body, to determine the skill in their profession, and the fitness to practice it, of all candidates who should offer themselves for examination. It was intended that the successful candidates should receive the “approbation of the society,” in letters testimonial of such examination. The members of this body, consisting originally of but thirty-one and limited to seventy, were termed Fellows, whereas those who passed successfully its examinations did not become, as now, members, but were simply licentiates, or men announced by the society as fit to practice medicine. An election into this body was made honorary, and only conferred upon those who had arrived at some distinction in the profession. Some of the Fellows were distinguished members of other professions. It was formed somewhat after the model of the English educational bodies of that day, such as the Royal College of Physicians. This arrangement did not prove popular; there was an unwillingness, on the part of those already in practice, to submit to the examination of the society or to acknowledge the supremacy thereof, without enjoying professional equality with the Fellows. Such distinctions not being “in accordance with the spirit of the institutions” of the young republic. Accordingly in 1803, the number of professional men in the State having greatly increased, a radical change was made in the constitution of the society, an extensive correspondence having been instituted among its members in order to devise the best means of increasing its usefulness. The plan was to embody the whole of the regular profession in the State, and by means of the authority derived from the legislature, to regulate the requirements of a medical education, so as to elevate the general character of the whole profession. For this purpose the limit of numbers was taken off, and every physician after three years of practice was entitled to enrollment as a member.

In the acts authorizing this important change we find the first public mention of the Councilors, although they constituted the working body of the society from its beginning. To them, at all events, were intrusted many functions previously performed by the Fellows. It was evidently intended by those who wrought this change that the governing body, although all members were now equal, should maintain that parental attitude towards the members throughout the State which the Fellows previously held towards their licentiates. They were chosen at the annual meeting, and exercised a general supervision over the affairs of the society. The election of all officers was in their hands, and it was left to their discretion to establish subordinate associations in such districts of the commonwealth as they might think expedient, or to subdivide or alter any of them whenever the public good might seem to require it; and it was expressly provided in this early act that “the members of such subordinate societies be holden to report to the Councilors of the general society all such cases as may be selected for their importance and utility” showing the purpose for which these societies were to be formed and the correlative duties which thus devolved upon them. The business of determining the qualifications of any individual who might apply for membership was delegated to a board of Censors, but the Councilors were permitted to elect those in practice at the time of the act and for some time after, and also honorary members.

The Censors consisted at first of a single board of five members. We find them mentioned in the list of officers under the original plan of organization. As new district societies were formed additional boards of Censors were appointed. In early time the Censors had great responsibilities forced upon them, for in 1817-18 general laws were passed by the State compelling the society to examine candidates for a license to practice, and depriving all who were not graduates of a school or licentiates of the society from legal privileges in collecting fees. In 1831, the clause requiring a successful candidate to practice three years before becoming a member was rescinded, and in this year also the Legislature compelled the society to accept the graduates of Harvard as members, but subsequently, in the acts of 1836 and 1859, it was provided that the society should not be allowed to discriminate in favor of any institution, and that all applicants should be treated alike. In the mean time, however, the State largely relinquished direct control over the practice of medicine, and as in the other professions gradually left it to take care of itself; since then the society has exerted its power for good in this direction solely through its influence upon public opinion and in maintaining a high standard.

The district societies owe their existence to the parent society. Their status was defined in 1803, as already indicated in speaking of the powers of the Councilors. “Before 1850 there were district societies only here and there in the State established at irregular intervals. In 1850 the Councilors divided the whole State into districts, in each of which they established a society. An addition to the charter of that year gave to the district societies the privilege of choosing Councilors and Censors.” This reorganization as it were of the districts was preceded in 1831, and again in 1848, by considerable discussion as to the relations of the districts to the parent society. One of the more active and powerful and at the same time one of the most distant subdivisions of the society was in Berkshire. It was apparently felt by certain members of this district that heavy burdens were imposed upon them, and that for obvious reasons they were unable to participate in the privileges of the society. The different portions of the State were at that time far less accessible to one another than at present. It was a much more difficult matter for a member to attend the meetings of the society, or to avail himself of the advantages of the library which it then possessed. As the meetings were held in Boston, and the funds and library were also there, it was evident that there was a growing feeling of discontent in a section of medical activity at the western end of the State, forgetting that Boston is nearly the geographical centre of the State, and in accessibility quite so, and this eventually found expression in the presentation of a memorial to the Legislature in 1831. No legislative action having been taken, it was finally brought up in a memorial to the society in 1848. The proposition of Dr. H. H. Childs and others contemplated that the State society should be constituted by delegates annually chosen by the county associations agreeably to the principle adopted in most of the States, thus making the basis of the society local or county associations. The petitioners claimed, in urging the measure, that the objects for which the society was first brought into existence had been completely overturned, a license being no longer required for the practice of medicine; no laws of the State or of the society were now of avail in guarding the entrance of the profession. In order to obtain such united action from the profession as could best protect and advance its interests a new plan should be devised, which would bring in a good many respectable men who were not members. The plan which was to smooth out all these difficulties was somewhat vaguely stated as “associated union.” The majority report of the committee to whom this whole matter had been referred was presented to the Councilors by Dr. Pierson, of Salem, and showed clearly that the simple and efficient plan of the society had accomplished all that was ever intended by its organization in 1803; that it would be unwise to desert a system which had worked well for half a century; that it was regarded by physicians in other States and countries as a most desirable model of medical organization; and that nowhere in our country, if in any other, could be pointed out a more respectable body of practitioners, or one more highly estimated by the community. Experience since that time has amply justified the views expressed by the committee, and the society now presents an organization less cumbrous in form and in better working order, probably, than any other in the world.

It was at first supposed that the society would become a scientific body, which could discuss and diffuse medical information and improvements, and take rank among the institutions of learning and science. Later, when it embraced the whole profession, the professional and scientific work was in a great degree delegated to the districts, and the general society became more especially a regulator, in conjunction with the State, of the practice of medicine, although at the annual meetings the amount of professional work is yearly increasing, and the society encourages original work on the part of members by the offer of annual prizes. Its most distinctive feature has always been the establishment of an educational standard, and in this it was aided by the government, to protect the public against the introduction of improper persons to the practice of medicine. It should be distinctly understood that it was in no sense intended for the mutual protection of physicians, for individual practitioners can get on very well without the society, and the number of those whose incomes are encroached upon by irregulars is exceedingly small. Its objects were effected first by the diffusion of medical knowledge among physicians. Prescribed courses of study were laid down for those who proposed to undergo the examination of the Censors. The society was in fact equivalent to a medical school, and at the time Harvard began to issue medical degrees the society protested against this supposed encroachment upon its privileges. The medical literature of the day was made available to members. The first Pharmacopœia published in this country was prepared for their use, and the society had no small share in forming the first Pharmacopœia of the United States. To the community it lent its valuable aid from time to time, as occasion required it. Questions of great importance were investigated by its committees, from whom many valuable reports emanated. A striking illustration of this kind of work is afforded in volume of the “Communications,” where we find an elaborate report on vaccination read at the annual meeting, June 1, 1808. The almost complete immunity of the city from small-pox for nearly a third of a century following shows how faithfully the profession of that day performed its task. During epidemics of spotted fever and cholera the activity of the society was conspicuously displayed. Its salutary influence was exerted in behalf of the law to encourage the study of anatomy, this State being the first to set the example of such enlightened legislation. Among the latest achievements, the abolition of the antiquated coroner system and the substitution of the medical examiner, whose important duties are throughout the State performed by members of the society, who have lately formed themselves into an association for the purpose of medico-legal studies. It was under the shadow of the society's wing that the first Board of Health in the United States was organized. And last but not least, the great boon of anæsthesia was given to the world through the agency of its members. The new code of ethics prepared last year by a committee of the Councilors should not be overlooked. It will undoubtedly serve as a model for all future codes, and has been most favorably commented upon throughout this country and in Europe.

I will now call your attention to a few typical examples of national medical associations, and to certain of our state societies whose organizations present peculiarities worthy of study.

For a number of years medical societies assembled in various parts of Europe, Switzerland being the first to hold a meeting of medical men. France and England followed her example. Italy had a gathering of physicians as early as 1839 at Pisa. It was at the annual meeting of the French Medical Congress at Bordeaux, in 1865, that it was proposed to hold an International Congress at Paris during the great exhibition of 1867. Professor Brouillard, the president of the Congress at Bordeaux, was authorized on his return to Paris to organize an executive committee, to whom the preparation of the coming meeting should be intrusted. It was intended that these gatherings should be purely scientific in character, and that there should be no official recognition by the schools or government; that they should last two weeks, and be held biennially. Foreign nations were invited to join, and their representatives were received at Paris as guests, the expenses of the meeting being borne by the French members solely. Since that time a fee has been usually demanded from each member. The preparations for each meeting are perhaps more elaborate than those of any other association, each country vying with the others in the perfection of its arrangements. Circulars are first freely distributed by the committee some eighteen months in advance, and the cooperation of the journals and societies requested. Several subjects in the earlier meetings of the Congress were selected for discussion, and were printed with an outline of the general character of the discussion it was intended to have. These occupied the day-time at the Paris meeting, while the evenings were given up to miscellaneous papers and discussions.

The first day opened with communications on the “Pathological and Physiological Anatomy of Tubercle.” Other papers read at this meeting were, “On the Influences of Climate, Race, and Condition of Life on Menstruation in Different Countries;” “The Accidents which cause Death after Surgical Operations;” “Prophylactic Measures to prevent the Propagation of Venereal Diseases.” It was found that the difference of language was a great obstacle to the success of the meetings, and that the formal discussions were lengthy and tedious, many of the papers being read for the authors. The attractions of the city, and exhibition detracted largely from those of the Congress. The attendance was large; there was a fair number of celebrities, and all countries were represented.

The second medical olympiad, as it was termed by Professor Brouillard, was held in Florence, in 1869, Professor Salvator being the presiding officer. The general plan of the meeting was similar to that held at Paris. The chief subjects of discussion were, “Marsh Miasm;” “The Therapeutics of Cancer;” “The Treatment of Gun-Shot Wounds;” “Hygiene of Hospitals;” “The Influence of Railways on the Health of Man;” “The Conditions which favor the Production of Epidemics in Large Cities;” “The Rights and Duties of Medical Men in Relation to the Government and the Reforms which may reasonably be expected.”

The third meeting was held in Vienna, in 1873, at the time of the great exhibition in that city, with the venerable Rokitansky as its president. The subjects discussed included, “Vaccination,” “Syphilis and Prostitution,” “Cholera and Quarantine,” “Freedom of Practice in all Countries for Qualified Men,” “Hygiene of Large Towns.” A universal Pharmacopœia was proposed, and was further discussed at the next meeting in Brussels, without any definite plan having been arrived at. This Congress does not seem to have been so successful. There were about two hundred members, but the attendance was not satisfactory, the attractions of the exhibition being great, and especially of a very fine exhibit of military surgery. The physicians of Vienna do not appear to have attempted a publication of the proceedings, which came out in abstract three years later, under the auspices of their successors.

Brussels entertained the Congress in 1875, Dr. Hennincke, the president, opening the proceedings in the presence of the king. At this Congress the work was for the first time handed over to “sections”; each department preparing questions beforehand for debate. There was a general meeting at midday, and in the afternoon the various sections held their sessions, at which a large amount of work appears to have been accomplished. This plan of organization has been retained since.

The next year being the date of our centennial celebration an extra (but apparently unrecognized) session was held in Philadelphia. I need not remind you how ably the committee having the work in charge carried out their programme. Although there were but few delegates from Continental Europe, Great Britain furnished a large number of representatives, with whose names and writings we are all familiar. With the venerable and distinguished Dr. Gross as president, and such men as Lister, Tufnell, Barnes, and Adams to participate in the debates, the meetings could hardly fail to prove most interesting.

In 1877 the Congress met at Geneva, under the presidency of Dr. C. Vogt, and was largely attended. There were numerous agreeable social features, which the picturesque locality made additionally attractive. The volume of reports is by far the most elaborate, there being also a number of very fine illustrations. There was an exhibition of instruments.

The meeting at Amsterdam, in 1879, was notable for the attendance of many scientific men of eminence. Donders was its president, Virchow was among the members, and one of the general meetings was made memorable by a sort of ovation to Lister. The social features, as usual in Continental towns, were an attractive feature.

The next meeting of the Congress is to be held this summer in London, and English physicians have certainly thus far left nothing undone to make it the most brilliant of the series. Work began over a year ago, circulars being freely distributed to all journals and societies. In this way cooperation has been obtained from foreign countries on all sides, and the organization of the various sections and the preparation of the work have been greatly facilitated. The session will open August 2d, and continue through August 9th. All legally qualified practitioners will be received on the payment of one guinea; membership will entitle one to a copy of the Transactions. It has been decided not to admit female physicians to the meetings of the Congress, but ladies will be invited to attend the social gatherings. Arrangements have been made to hold a medical exhibition at the South Kensington Museum, on a scale which has never before been attempted: it will be opened a fort night before the meeting of the Congress.

The work has been divided up among no less than fifteen sections, which will occupy the mornings, and in the afternoon there will be a general meeting, when addresses by Huxley, Volkmann, Billings, and others, and communications of special interest, will be listened to. This and the meeting of the British Medical Association in the Isle of Wight, this summer, will prove a great attraction to American physicians.

The organization of the International Congress is of a very simple character, each meeting being completely independent of its predecessor.

The British Medical Association was founded in 1832, by Sir Charles Hastings, of Worcester. It was designed by the founder to remove the disadvantages under which provincial medical practitioners labored, owing to their isolation and want of cooperation. It is a scientific, a benevolent, and an ethico-medico-political association. Its objects are attained by means of periodical meetings, by the publication of a weekly journal, and occasionally of transactions and other papers, and by the appropriation of certain sums of money for the promotion of the medical and allied sciences. It was at first a purely local association, but gradually extended so as to include London, Scotland, and Ireland. In 1874, the association was incorporated under the Board of Trade, in accordance with the “Companies Act of 1867.” The governing body is a board of directors, called the committee of council, which is composed of twenty members, elected by the council, and includes certain officers, who are ex officio members. The council consists of the president and other officers and representatives, elected by the various branches of the association, each branch electing one for every twenty, together with an honorary secretary. In addition to its duty of electing the committee of council it prepares an annual report of the state and proceedings of the association, proposes the place of meeting for each year, and nominates a president. Practically, however, it has little power, being generally satisfied with registering the decrees and nominations of the committee of council, which has complete control, the management of the affairs of the association being thus kept in the hands of a few men. The number of branches of the association is between thirty and forty. They embrace 7500 members, being one third of the registered members of the profession in the United Kingdom. At the annual meetings, addresses are delivered by the president and the presiding officers of sections, when discussions on special subjects take place. There are sections of medicine, of surgery, of obstetric medicine, of public health, and of physiology. Committees are appointed at the annual meeting to carry out the wishes of the association and advance professional interests. These are the medical reform committee, the parliamentary bills committee, and the scientific grants committee. The last was appointed in 1874, to distribute the £300 annually voted by the association to forward original research. The second committee was appointed in 1863, and has rendered valuable service by considering all bills introduced into Parliament in any wise affecting the interests of the profession or touching the public health: amendments suggested by the committee are often adopted by the government. It also watches over the interests of the medical departments of the army and navy and the marine service.

The medical reform committee was appointed in 1852, and has for its special duty the advocacy of improvements in the law regulating the practice of medicine; and in order to understand the attitude of the association towards the question it will be necessary briefly to allude to the license law, or, as it is termed, “registration,” in the United Kingdom. This system is supervised by a body known as the General Medical Council, composed of representatives from the different examining bodies throughout Great Britain and Ireland, and several members appointed by the Crown. These are the bodies whose diplomas are recognized by the council for registration, and no man can be a legal practitioner unless he is entitled to be placed on the medical register. It must be remembered that these licensing bodies, seventeen, or as is more lately stated nineteen, in number, such as the Royal College of Physicians of London, of Edinburgh, of Ireland, and the universities, are not necessarily charged with the teaching of medicine, which function is performed by the medical schools, of which there are in London alone a large number, attached to the several hospitals. Registration is not made compulsory, nor can any penalties be inflicted upon an unregistered person who, having obtained a diploma, practices in accordance with such qualification; but without being upon the register no one can recover fees in a court of law, nor hold a government position, nor sign medical certificates: he is wholly shut out from official medicine. Those who practice without a diploma can be prosecuted in case they assume a title recognized on the register, and are then liable to a fine of twenty pounds for each offense. The eclectic and homœopathic practitioners are not sufficiently numerous or influential to secure a representative in the council: no such effort has, at all events, been made.

Although all the diploma-granting institutions are thus united under one controlling body which secures a minimum of requirements, the standard of excellence is a very varying one, and attempts have been made to form an examining board which would represent all these bodies, and also to institute a state diploma which should be compulsory for all students before their names could be placed upon the register, but as yet without success. The constitution of the council is apparently not satisfactory to the profession, as both the association and the prominent journals have favored a reorganization upon a basis which would represent the profession at large, rather than the diploma-granting bodies which it is intended to control.

It will thus be seen that the organization of the association is such that it is able to exert a great deal of influence, not only in matters pertaining to the welfare of the profession itself, but also in legislation bearing upon state medicine.

There are several prizes: the Hastings medal; two triennial prizes, being the interest on certain sums presented by members of the association; and a medal for “distinguished merit,” awarded to any member of the profession for heroic conduct or special services to the association.

The management of the British Medical Benevolent Fund, which has an annual income of over $3000, has been in the hands of the association since 1835.

The special feature of the association, to which is due in a great degree its brilliant success, is the British Medical Journal. This weekly periodical had its origin in the volumes of Transactions, nineteen of which have been published in twenty-one years. It was first started in 1840 as The Provincial Medical and Surgical Journal. In 1844 it became the official journal of the association, and was at first controlled by a committee. This was not a very successful arrangement, and the journal was transferred to Worcester, where it was issued once a fortnight. In 1853 it was again taken to London, and published as the Association Medical Journal, under the editorship of Dr. John Rose Cormack. In 1856 the present title was adopted, and ten years later Mr. Ernest Hart, the present editor, assumed charge. Under his able direction the circulation, and with it the membership of the association, increased from 2500 to over 7500, and additions to this number are constantly being made. The magical effect of the influence of the journal upon the association is graphically described by Dr. Sayre in his address, delivered last June, before the American Medical Association, wherein he advocated a similar experiment in this country. The proceedings of the association appear promptly; every address or article, with the discussions to which they have given rise, appear in the pages of the journal; and as work is going on the year round there is a constant supply of material, and the interest is kept alive. As Dr. Sayre truly remarks, “Certainly in this way the British Medical Association has become the most powerful medical association in the world.”

The fundamental idea which brought about the formation of the American Medical Association was the improvement of our system of education. During the fifteen years intervening between 1830 and 1845 the number of medical colleges in the United States more than doubled. The competition was great, and short courses of instruction and easy terms of graduation were consequently the rule. Sixteen weeks were very generally adopted as the length of the college term, and in some of the schools it was reduced to thirteen. At the meeting of the Medical Society of the State of New York, in 1839, when the subject of medical education was brought forward, it was proposed to hold a national medical convention in Philadelphia the following year, consisting of delegates from the societies and schools of the different States. No response was made to the action of the society. In 1844 the New York society made a second movement in this direction, Dr. N. S. Davis, a delegate from Broome County, New York, offering a resolution that a national convention be called to meet in New York in 1846, the organization of which was intrusted to a committee, of which Dr. Davis was chairman. On this occasion there was a general response from all quarters except Philadelphia and Boston. The proposed convention assembled in May, 1846, and Dr. Jonathan Knight, of New Haven, was chosen president. Committees were appointed, and resolutions in favor of the formation of a national association and elevation of the standard of medical education were adopted. The convention reassembled the following year, and, after listening to the reports of their committees, resolved itself into the American Medical Association, and elected Dr. Nathaniel Chapman, of Philadelphia, its first president. The two systems discussed at this meeting as the basis of membership were, first, “the delegate,” which has since become so familiar to American physicians, and which was adopted; and, secondly, that proposed by Dr. Isaac Hays, which contemplated an organization, the members of which should be elected by itself, either directly or through a board of councilors, thereby making it independent of state and local societies and institutions. It was thought that the latter plan would give the association greater stability, and make membership more select and permanent, while it was argued that the former would give the association more influence among the profession at large, and would favor the development of state, county, and city societies throughout the Union. The delegate system was adopted; but finally, in 1874, delegates from hospitals and colleges were excluded, the state and county societies, which are recognized by their own state society, alone being represented. Even this modification does not seem to have proved very satisfactory, for in 1877 it was proposed by the president, Dr. Bowditch, that every member of a state society should be ex officio a “permanent member,” the number of delegates being greatly reduced. But this plan was objected to, a committee subsequently reporting that it would be desirable if uniformity of organization and the payment of fees could be secured. It is interesting in these early meetings to note the character of the resolutions bearing upon medical education, having in view increase in the length of term, the necessity of a full three years’ course of study, a higher and more uniform standard of preliminary education, and the separation of the teaching from the licensing power.

A prominent feature of these meetings was reports from standing committees on medical science, on practical medicine, on surgery, on obstetrics, on medical education, on medical literature, and on publication. At the second meeting in Baltimore the report of Dr. Holmes on medical literature justly criticised the proneness of American writers of that period to content themselves with the position of editors of foreign works, and the character of our periodical literature, and urged the substitution of original for parasitical authorship. The beneficial effect of such criticisms from the association is indicated by Dr. Davis in his presidential address in 1865. When the association was formed publishers would not take books from American authors. The influence of the association had, he thought, already at that time wrought an entire change. The second annual meeting was held in Boston, and Dr. John C. Warren was elected the third president. It is particularly worthy of note at the present time that in connection with the report of the committee on medical education a paper was presented from the faculty of Harvard University opposing the proposition to extend the annual college terms to six months. It was at this meeting that social features were introduced, an entertainment being offered to the association by the physicians of Boston.

Already at the third meeting an interest in public hygiene began to manifest itself, and papers on subjects pertaining thereto were offered from Boston, New York, and New Orleans. An appropriation having been made for two annual prizes, the first was awarded at the fourth meeting, in Charleston, in 1851, “to Dr. John C. Dalton, Jr., for the essay ‘On the Corpus Luteum of Menstruation and Pregnancy.’”

The annual reports of committees, containing abstracts which were lengthy and uninteresting, were soon abolished, the number of committees being enlarged to thirty, and special subjects being assigned to each.

At the next meeting we find the association memorializing Congress in regard to abuses in the merchant marine, and as early as 1852 the propriety of substituting a periodical journal for the Transactions was suggested by Dr. J. B. Flint, of Kentucky. This proposition has been advocated since by Drs. Gross, Sayre, and Parvine, at different meetings, as it was thought that no other measure would promote so efficiently the prosperity of the association, and in this view they are undoubtedly correct.

The association early felt the importance of medical organizations in the different States; but few state societies and smaller local societies had been formed, and the masses of the profession had not only no coherence, but were actually separated. A committee was appointed to draw up a plan of organization of state and county societies, for the purpose of facilitating and encouraging such formation. It was suggested in the report that the counties should be made “auxiliary” to the State, and the state societies “auxiliary” to the national association. As the importance of maintaining a high standard of education was not forgotten, each State was strongly urged to include in their plan the formation of a board of Censors. It was contemplated that the counties should send in reports from its individual members to the State, and the States in their turn should make return to the parent society, thereby establishing a concert of action throughout the country.

Dr. Chaillé says in regard to this point: “In fine, the most important duty of this association is to devise ways and means to organize the medical profession in county societies, to gather these into state societies, and to aggregate the whole into this association, and to induce each physician to contribute $10 to $15 to support the three societies. The association would thus obtain a revenue of $200,000.” Such a plan, attractive as it may appear, would be impracticable at the present time. It would be difficult to collect fees or to persuade members to take an active interest, judging from the experiences of state societies. For instance, in 1878 Georgia dropped 300 of 547 members for non-payment of fee.

The code of the committee referred to above did not prove satisfactory, for we find Drs. Gross and Davis stating, in 1878, that many of the state societies were little more than annual mass-meetings, and that there was no uniformity in the plans of organization.

It has been proposed since to improve upon the old code, and to publish in the Transactions annually a statistical report of certain specified details for every state society; also, peculiarities of its regulations, or measures it is using to promote its efficiency. The state societies have also been requested to publish a register of the members of the profession in good standing. No society, however, has complied, although many local registers are published.

The plan of committees to report on special subjects proving a failure, all special work was, in 1860, referred to the “sections,” which by holding simultaneous meetings accomplish a far greater amount of work.

The next great improvement in organization was effected in 1873, when the formation of a judicial council satisfactorily disposed of what was becoming a great source of annoyance and impediment to work, — the discussion of local questions of ethics at the general meetings. The council consists of twenty-one members, seven new members being added each year, and seven retiring.

As in the earlier meetings the presidential addresses teemed with suggestions on the subject of medical education, so in later years we find the growing interest manifested in public hygiene. Since 1870 this has been strongly marked. In 1871 the association urged that a professorship of hygiene should be established in every medical college, that every state government should be memorialized to establish a board of health, and that members should use their influence to induce Congress to form a national board. In 1873 a section of state medicine and public hygiene was formed. In the Transactions for 1879, the exceedingly valuable and interesting paper by Dr. Chaillé, of New Orleans, on “State Medicine and State Medical Societies,” and papers on “Protective Sanitation,” by Dr. Storer, and “Registration of Disease,” by Dr. Balch, testify to the increased interest in these matters.

The association does not appear to have taken any stand in regard to the perplexing question of medical license laws in the several States. It seems to have contented itself, and perhaps judiciously so, with recommending the exaction of preliminary education by boards of Censors, and later in advising the societies to examine all practitioners, whether graduates or not; in other words, with urging a high standard of excellence from each state society.

It has used its influence to secure improved rank for medical officers in the army and navy, and its repeated efforts through committees have undoubtedly helped to give us the first volume of the Index Catalogue.

Resolutions have also been passed, having in view the prevention of criminal abortion, and reform in the methods of securing expert testimony.

This brief sketch is sufficient to show the character of the work attempted by the society, and to enable us to estimate roughly what it has accomplished. The medical mind throughout the country was roused into activity by its formation. Although the early work in aid of medical education had little apparent effect at the time, undoubtedly it may fairly claim a share of the influence which has brought about the great changes of the last decade. The questions of public health, which have lately been so prominent, have reminded us of the usefulness of such a body, when well managed, in time of need. The result is certainly more satisfactory than one might have expected, considering its diminished popularity in the Eastern and Middle States during the last ten or fifteen years of its existence. The class of medical men who take an active part in the work of the association are no longer of the same stamp as those who attended the meetings in the early years of its life. But comparatively few of the prominent men of the country are now to be seen at the annual gatherings. The causes of this decline it is not difficult to find. The delegate system of membership, which was not adopted without opposition, seems largely to blame for this unfortunate result, offering as it does but little inducement for membership, and opening the door to any one who may wish to make this an excuse for a pleasure trip, or who may desire to use the association as a means of personal aggrandizement. The ever-changing character of the material of this body gives it a lack of stability and permanency which must necessarily greatly impair its efficiency. The conditions which exist in this country are to be met only by an organization specially devised for the purpose, and it would clearly be impossible to select any other national association for a model. The lack of uniformity in our state societies would prevent, for instance, the adoption of so simple a plan as that of the British Medical Association. In 1872 this question was freely discussed in the medical journals, and amongst other plans it was proposed to establish a national council, a sort of medical senate, the members of which were to be elected for a term of years by state councils, whose members in turn should be selected from congressional districts. To such a body would be intrusted the scientific and professional business of the association. Eventually, the various state and county societies might be included as branches and sub-branches of the parent society. An important element in the success of any such large body of medical men is the inducements which it offers to each individual to become a member. He must see a substantial return for the money annually paid in assessments. The sum is usually larger than the average practitioner can afford to spend for objects, the usefulness of which may appear to him somewhat remote. The annual volume of Transactions does not supply this need. The work of the annual meeting does not appear until many of the questions it has discussed have, in these rapidly moving times, lost the vitality which made them topics of special interest at the moment. During the greater part of the year the association is a blank; beyond the feeble efforts of a few committees, its work seems to have come to a stand-still. Nothing is known of the coming meeting by the profession at large. Contrast this fact with the methods adopted by the International Congress: how much more we know about a meeting which is to take place three thousand miles away than we did beforehand of one which has taken place at our very doors! The publication of a weekly periodical would not only fill this void for each individual, but would be a powerful incentive to the association for continuous work throughout the year. This would of course necessitate a radical change in the organization of the society, which is perhaps the reason why its leaders have shrunk from taking the step.

The future of the association depends largely upon the success with which it identifies itself with the interests of the state societies. It should become a bond of union between them, the usefulness of which should be made so apparent that all would be glad to avail themselves of it. To effect this object, the present organization must be discarded, and an active and vigorous body must take its place, making its influence perennial, and appropriating for its highest offices the ablest men in the country. With such machinery the profession of the United States would, I think, be startled to find the power which it would be able to exert.

The Medical Association of the State of Alabama was organized in 1848, and reorganized in 1873.

The objects of the association are stated to be the organization of the medical profession of the State in the most efficient manner; to encourage a high standard of medical education, and regulate the qualifications of practitioners of medicine; to watch over and protect all the interests of the medical profession of the State; and to supervise the sanitary laws and interests.

The peculiar features of this association are the attitudes which it has assumed towards the regulation of the practice of medicine and its public health system. The various boards of censors assume the double duties of examining boards and boards of health for the State at large, and for its various counties respectively.

The draft of an act to regulate the practice of medicine was submitted to the association in 1874, and became a law in 1877, after an active opposition in the Legislature. The leading features of this law are as follows: The state and county boards of censors are constituted boards of medical examiners, from whom all persons intending to practice medicine in the State must obtain a certificate of qualification after passing an examination. All persons legally engaged in practice at the time of the passage of the law are continued in the enjoyment of their rights under certain regulations. It has been found expedient not to molest any practitioner actually in practice at that time, even though he be thus engaged without the authority of the law, except in notorious cases. The examinations for those who propose to practice the “regular” system of medicine include anatomy, physiology, elements of chemistry, organic and inorganic, materia medica, therapeutics, pathology, theoretical and practical medicine, surgery, obstetrics, hygiene, and medical ethics.

Those who propose to practice some irregular system are examined only in chemistry, anatomy, physiology, and the mechanism of labor. The examinations are partly oral and partly written.

There are preliminary examinations laid down for those who intend to begin the study of medicine, which include English grammar and literature, outlines of history, elements of arithmetic, algebra, geometry, physics, or natural philosophy.

The certificate of the board is duly registered in the probate court of the county. After having passed the examination, the successful candidate, if a “regular,” is generally elected into the county society. Up to the present time the county boards have been engaged for the most part in the preliminary work of issuing pro forma certificates to those already engaged in the practice of medicine. They have also made a few examinations of applicants who propose to practice the regular system of medicine. Practitioners of the peripatetic class have as a rule declined to come before the boards, when summoned to do so, and have preferred rather to leave the State. Numerous cases of this kind have occurred. The penalty for violation of the law is a fine not exceeding one hundred dollars, and in default of payment imprisonment for not over one year.

In one of the reports of the censors regret is expressed that provision requiring the examination of irregular practitioners has been introduced, as it thus elevates irregular medicine into a position of quasi-respectability, and “because it will, perhaps, give a somewhat longer lease of life to systems of practice that are already falling into decay, and that should have been allowed to die as quietly as possible, without being temporarily galvanized into an appearance of vitality by legislative action.”

The association has in view the annual publication of a complete register of medical practitioners of the State.

The State Association is also made the State Board of Health, and the functions of county boards of health are invested in the several county medical societies, “thus virtually engaging all the doctors of the State in the sanitary service of the people, and in the administration of the health laws of the State.” The bill proposing this measure was passed in 1875. In 1879 an act was passed appropriating three thousand dollars for the use of the state board. The county boards enjoy only advisory powers, and are conducted without expense to the State. Under certain emergencies they may be invested with extra powers and duties by the legal authorities.

It is proposed to pass an act this year to provide for the supervision of the public health, and for the collection of vital statistics. This act specifies more accurately the duties of the various boards, including the supervision of all public institutions, and all matters pertaining to quarantine and quarantine physicians. Each county board has a health officer at a salary of not less than one hundred dollars a year, who is the executive officer of the board. He attends to all the specified duties, is prepared to vaccinate and perform any additional duties which may be assigned him. He must keep a register of births and deaths and infectious diseases, and every physician, midwife, or citizen is expected to send to him full reports. He is obliged to make weekly, monthly, and annual reports to his board of all business done in connection with his office, and the county boards make to the state board an annual report, “containing all the vital and sanitary statistics of the county,” and any other information that may be deemed adisvable. The health officer may have assistant health officers appointed to aid him in this work. Fines maybe inflicted to compel information upon the desired points. The state board can declare quarantine measure when thought necessary, and twenty thousand dollars are annually appropriated for quarantine purposes. This board may also have its health officer, if deemed important. His term of service lasts five years, and he is paid out of the annual appropriation first mentioned. His business is to conduct the correspondence of the state board, to assist in organizing and conducting the county boards, and to take charge of the annual reports.

Ordinances exist also for the regulation of the practice of pharmacy and the practice of dentistry in the State. Attention should be called to an important recommendation in the last report of the censors, “that no laws affecting the interests of the medical profession in any way should be allowed to go before the General Assembly without first having received the indorsement of the association.”

In the Transactions for 1875 we notice the following significant remark: “We will appreciate most adequately the real character of the association if we regard it as a medical legislature, having for its highest function the governmental direction of the medical profession of the State, while its other functions, important as they are in themselves, are, in comparison with this, of quite subordinate rank.”

Undoubtedly the work to be performed by this very energetic body will produce satisfactory results, and the plan may prove the one best adapted to the present needs of the State, being perhaps the most effective that could be devised for inculcating a due appreciation of the laws of public hygiene and raising the standard of the profession in Alabama. The experiment of such a species of medical legislature should be watched with interest by the profession, as whatever may be its fate its experiences will be most instructive to similar bodies throughout the country.

The Medical Society of the State of North Carolina has an organization similar to that of Alabama. By an act passed in 1877 the society was constituted the State Board of Health, the county societies becoming the boards of health for the various counties, under the direction of the general board; these boards receiving from the competent legal authorities any necessary powers for carrying on their work as may be agreed upon. No other boards are allowed to exist, the object being to secure a uniform system of sanitary supervision throughout the State. The sum appropriated for this work by the Legislature was at first but one hundred dollars, but this has since been increased to two hundred dollars; and it is expected that the state government, having appreciated the great advantages of such an organization to the welfare of the State, will establish it upon a basis more on an equality with other departments, as that of agriculture, as a “health department,” with perhaps a “commissioner of health” as a state officer, and that it will become auxiliary, if properly managed, to the board of education. It is stated that the object of this plan is to preserve the board from the contamination and corruption of political parties. In a supplemental act passed in 1879, it was provided that the board should consist of six members elected by the society, and three members, one of whom should be a civil engineer, appointed by the governor. The board is disposed to cooperate heartily with the national board of health. The latest accounts show that the board is actively at work, and endeavoring to organize a system of registration for vital statistics, and to inculcate elementary sanitary principles among the people. The secretary complains of the ignorance of government officials and the indifference of physicians.

An act of 1859 authorized the organization of a board of seven “regularly graduated physicians” under the title of the Board of Medical Examiners of the State of North Carolina, the board to be appointed by the society, unless the Legislature choose to exercise this right, of which it has never availed itself. The term of office is six years. The board meets yearly with the state society, and continues in session until all applicants have been examined, receiving pay for services. Temporary licenses may be granted at other times of the year by any two members of the board. This law, although not making it unlawful for non-licentiates to practice, deprives them of the privilege of collecting fees by legal process. Those practicing at the time of the passage of the act were not affected by it. The law has forced many unwilling physicians to undergo an examination for the license, and many have failed to pass the board.

The Texas State Medical Association was organized in 1869. As is usual in most States, the county societies are represented at the meetings of the state society by delegates, two of whom are chosen for every ten members. The medical colleges in the State are represented in the society, each school having two votes. There is a council of twenty-one members, to which all questions of an ethical or judicial character are referred. The association has not succeeded in establishing a state board of health; there is a law authorizing local boards, but it has proved of little value. The chief work has been the establishment of a law regulating the practice of medicine. This was secured in 1873, but has since been modified. It has been framed in accordance with a provision of the constitution of the State that “no preference shall be given by law to any school of medicine.” The examining boards, consisting of three practicing physicians, are appointed by judges of the district courts. Every person intending to practice medicine must undergo the examination prescribed by the board. The penalties for non-compliance with this law vary from fifty to five hundred dollars. The licensing power is thus placed entirely under the control of the State. The judges of district courts are supposed to be officers of sufficiently high standing to be intrusted with the formation of efficient boards, although it has been thought, by those familiar with the medical acts of other States, “that this system offers the best solution of the difficult problems arising from the various divisions of the medical profession.” It is stated by Dr. Chaillé that in some districts difficulty has been experienced in organizing the boards owing to the appointment of homœopaths.

The society has interested itself actively in calling the attention of the government to all matters pertaining to state medicine. Unsuccessful efforts have been made to obtain an appropriation for the Galveston Medical College, to enforce compulsory vaccination, to appropriate five thousand dollars for the cultivation of the Eucalyptus globulus, etc. In Louisiana an attempt has been made to provide for the maintenance of the University of Louisiana by the State; but in Michigan, where the state society succeeded in establishing a general hospital and a medical department in the University of Michigan, under state patronage, the government appropriated six thousand dollars to support two professorships for teaching homœopathy. Serious and constant trouble has resulted, and advocacy of the doctrine that “a State ought not to establish medical schools, nor support nor govern them.”

The Illinois State Medical Society possesses many points of peculiar interest. It is one of the oldest of the Western State societies, and was organized in 1850; its secretary, Dr. N. S. Davis, has been more closely identified with society work than any other man in this country, and its relation to the State Board of Health and the medical practice laws present an interesting contrast to those of the societies which have just been described. Of special interest to us is the plan upon which membership is based. Like many of the state societies which followed the pattern of the American Medical Association, the delegate system largely predominated. In addition to delegates, however, “permanent members” were also elected, apparently without any special plan. The consequence was that many men became members who were not in good standing, and many thus elected became alienated from the local societies; others took little interest in the society, and neglected to pay their fees. The feeling became prevalent “that most physicians care nothing for a medical society until sickness, adversity, or a suit for malpractice overtakes them.” The system was evidently an unsatisfactory one and liable to great abuse. It was found necessary to revise the constitution, particularly with reference to the election of members. This was done in 1878. At this time there were but 352 members, and at the annual meeting in 1878 the total attendance was 100 members in a State where there are 5000 practitioners. In the same year the attendance at the annual meeting of the American Medical Association was 526, and in Maryland, at the meeting of the state society, 150 members were present, being the largest number at any state meeting except that of Massachusetts.

In Wisconsin the society was almost destroyed by being “a delegated body,” through the neglect in organizing local societies, and of those organized to send delegates. The Wisconsin society now consists of permanent members entirely; for although delegates are admitted, these prefer to become permanent members. Such facts as these justify the action of those who refused to permit similar changes in the organization of our society.

Under the present organization in Illinois, effected in 1878, there are still delegates, who represent local societies, medical colleges, hospitals, lunatic asylums, and other permanently organized institutions in the State. After serving one year in this capacity, they become permanent members. There is a judicial council of nine members, whose term of office is three years. Its duty is to decide all questions of an ethical and judicial character.

The manner of dealing with public hygiene and medical license is in striking contrast to that of those States previously mentioned, the work being done independently of the society, although the latter has exerted itself to bring about legislation upon these matters.

The Illinois Medical Society appointed a committee to memorialize the Legislature to establish a board of health in 1876. The committee met with great opposition. They were assisted by a committee of the American Medical Association through Dr. Johnson, their chairman, and also by the profession of Chicago. The board has been partially successful in collecting vital statistics. Dr. Rauch, the secretary, states in the report for 1880 that the board has no power to enforce this portion of the law, which devolves upon the county clerks, who frequently claim exemption from the discharge of that duty, proper compensation and assistance not being afforded by the county supervisors. In this report he urges that a committee be appointed on the law regulating the practice of medicine, and another on vital statistics, both of whom to cooperate with the state board in securing sufficient enforcement of the laws. At the last meeting of the society in 1880, it was proposed to memorialize the Legislature to secure the enactment of a law to create a school board of health for each county, consisting of the superintendent of schools, the surveyor, and one physician, the duties of the board being to inspect all sites and plans for schools and their sanitary condition.

The time of the Board of Health has been chiefly taken up in carrying on a work which in no other State has been assigned to such a body, namely, the execution of the law to regulate the practice of medicine. The act was passed in 1877. In organizing the board the governor appointed three “regular” physicians, one homœopath, one eclectic, and two members at large. All physicians who had not been in practice ten years were required to show their diplomas to the board, that body reserving to itself the right to decide whether the school granting the diploma came up to a proper standard. If the candidate had no diploma he was required to pass an examination. These examinations have been largely “written,” and a perusal of the papers show them to be of a high standard. The fines for violation of the act vary from fifty to five hundred dollars. Quite a variety of classes of individuals were found undertaking to practice. Among these it is important to note, in view of certain similar tendencies in this State, that there were a number of colleges whose curriculum was too short, and the work of teaching too carelessly done, and others who did no teaching at all, although chartered schools, their function being the sale of diplomas. There were many holding diplomas that did not belong to them. Forty-one practitioners were found under assumed names. The board went actively to work: held meetings in different parts of the State, and in the first year issued over five thousand certificates. It was thought that the difficulties in the way of determining the status of the thousands of practitioners scattered all over the State would be insurmountable, but the examining body being also the State Board of Health, the provisions of the law requiring the registration of practitioners as a part of the machinery necessary for securing the vital statistics of the State became an efficient means of overcoming this difficulty. Dr. Johnson is of the opinion that for this reason mainly the regulation of the practice of medicine can best be attended to by state boards of health. He believes that the law should compel every practitioner to pass an examination, as it has been found practically very difficult to discriminate between diplomas from the various colleges.

There is published an annual “Illinois State Medical Register.”

At the last meeting, Dr. N. S. Davis, the permanent secretary, who for thirty years had served the society in different capacities, sent in his resignation, which was received and accepted with much regret.

Glancing at other States, it may be noted that in Arkansas futile efforts have been made to secure an insane asylum, a board of health, the registration of vital statistics, and a law to regulate the practice of medicine. An excellent plan in Indiana is the appointment of a committee of three on state legislation in each county. The state society has issued to members of the Legislature copies of articles published in its Transactions, on state medicine. Louisiana has been active in urging upon the Legislature the needs of state medicine. It has been said that no State in the Union was better protected against impositions of all kinds. A law to regulate the practice of medicine was enacted in 1808, and amended in 1816, 1817, and 1840. The various provisions were repealed in 1852, without encountering the opposition of any; “for such was the execution of these laws that the State was infested with quacks and patent medicines, and whilst the laws imposed taxes and other burdens on the good, their penalties against the bad could not be enforced.” In Mississippi laws to regulate the practice of medicine are deemed premature until better appreciated by the people. The new New York license law requires every practitioner to register, showing a suitable diploma. The penalty is a fine varying from fifty to two hundred dollars. This has the advantage of avoiding a mixed board, and does not oblige physicians to indorse any “sect.”

Having thus passed in review a number of associations of medical men, which, although in some cases formed for widely different purposes from our own, present peculiarities of interest to our Fellows, let us pause to consider whether we can gather from the experience of others hints which will be of use to us in carrying on our future work.

With the organization of our society we have certainly reason to be content. One of its greatest merits is its simplicity; there is no complicated system of delegates, “permanent” or “associate” members. By it the whole regular profession of the State is united into one compact body, which, through its council meeting at stated intervals, is able to do a large amount of work with a minimum of friction. The tables of Toner and Chaillé show in no State such figures as are credited to Massachusetts, which stands alone in wealth and numbers. Nowhere have I been able to find machinery which could do the work for which our society is designed in so satisfactory a manner. Under these circumstances we ought to be able to accomplish a great deal of good for the community in which we live. Let us glance, therefore, at some of the questions of the day which interest us as medical men.

Most prominent among these is the great question of public health or preventive medicine, the history of which dates back nearly one half a century to what may be called the period of its birth in modern times. It was after the cholera epidemic of 1830 that attention was first drawn to this question in Europe, and it is since that time that it has risen to the rank of one of the departments of science. The great work which has been accomplished in England also during this period has been of almost incalculable benefit to the civilized world. It is only, however, during the last decade that this vital question has actively engaged the attention of medical men in the United States. The first State Board of Health in this country was formed in Massachusetts in 1869, and to-day we have, besides the National Board of Health, similar boards in twenty-three of the States, in addition to numerous local organizations throughout the cities and counties of the country. Our recent pestilences have greatly stimulated this movement, which even with its present crude machinery has, on more than one occasion, demonstrated that sanitary science has not only been able to save life, but, what perhaps appeals more forcibly still to the American legislator’s mind, has been productive of results involving substantial pecuniary benefits.

There still remains much to be done, and doubtless many disappointments to be endured, before we reach the desired stage of perfection in this to the nation most vital department of science. When the General Board of Health came into existence in England it was so far in advance of public opinion that it soon fell to the ground, and a similar fate befell the splendid sanitary organization which was built up out of its ruins. The record of many States is far from encouraging. In Indiana there is still no board of health, but there are laws to protect animals from Texas cattle disease, fish from poisoning, and hogs from hog cholera. In Maine, where the state society has striven hard but unsuccessfully to obtain a board, there has been an annual appropriation of four thousand dollars for bounty on wolves, to protect sheep. When this argument was brought forward as a reason for asking an appropriation for the protection of man, the bounty was withdrawn. Unfortunately Massachusetts is not in a position to smile at the lack of appreciation of these important questions by her sister States. It has been said that our own state board, which in its original form served as a model for the whole Union, has been worse than abolished. Its efficiency has, in the opinion of medical men, been seriously impaired by the cumbrous machinery of which it now forms a part. The city board of health is in danger, and at a time, too, when we are threatened with a serious epidemic. It behooves our society, as an association of men who are better qualified to judge of the importance of these matters than any others in the State, to make its influence felt both by active interference through the agency of committees and by the dissemination of sound views on questions relating to the health of the community; and this, it seems to me, is one of the directions in which we are able to increase our sphere of usefulness. From time to time it has been customary to appoint committees for the purpose of memorializing the Legislature to protect the interests of the profession, or to offer testimony for or against certain questions brought before that body. This has been done, however, in a somewhat desultory manner, and it is more frequently the result of individual enterprise that the “hearings” at the State House receive the benefit of sound medical testimony. The British Medical Association intrusts this work to the Parliamentary Bills’ Committee, and it would seem eminently desirable that it should be placed in the hands of a permanent committee, who with time and experience would become a trained body of men, qualified to represent the society on all such occasions, and to give a well digested opinion on all medical subjects. As very crude notions are held by representatives of the people in this State not only of the practice of medicine but of state medicine, these questions should on every occasion have the benefit of all the light which the best talent of a powerful society is able to shed upon them. It would hardly be advisable to imitate the Alabama plan, and endeavor to obtain complete control of a work, portions of which are not within the physician's sphere.

One of the questions of the day which is beginning to attract the general attention of physicians, and on which an opinion will probably before long be expected from the society, is the regulation of the practice of medicine by means of legislative enactments.

The exaction of a requisite amount of medical skill by law is, as we all know, a measure which is of more vital importance to the public than to the medical profession; for experience has shown that the money which goes into the pocket of the charlatan would rarely, in his absence, be diverted into respectable medical channels. The suffering caused by the ignorant practitioner is, on the other hand, borne by the laity who patronize him. We should therefore let the public clearly understand that it is they we are seeking to protect, and not ourselves, in case we advise legal remedies for the evil. That the evil exists, and that it exists in a very aggravated form in this State, is, I think, denied by no one.

It was for the purpose of checking these irregularities that our society was originally founded, that the public might be able to discriminate between the honest and the wicked and ignorant. Until the year 1840, nearly every State afforded some protection of this sort, but with the period of development of the so called “sects” of medicine it has become inoperative or obsolete, or has been repealed. Connecticut had a law, dating back to 1792, empowering the state society to regulate the standard requisite for a practitioner. But in 1848 the same authority was given to the Botanico-Medical Society, in 1855 to the eclectics, and in 1864 to the homœopaths. Maryland also had a law authorizing the state society to examine and license, which was practically amended by a law in favor of Thomsonians. New York has had an almost identical experience, as also this State. The state societies after this period were obliged to content themselves with maintaining a high standard among their own members, thus making it always possible for the public to obtain the services of a well-educated practitioner.

All restraints having thus been removed, the more flagrant forms of quackery began to thrive, until the credulity of the public has been abused to an extent probably unparalleled in modern times. The enterprise to which unrestrained license has given rise has led even to extensive criminal practices, which it is acknowledged the common law is powerless to prevent. Many States have therefore found it necessary to enact laws to regulate a system which is so productive of evil, and such laws are now in force not only in those States already mentioned, but also in California, Kentucky, New Hampshire, Vermont, and Pennsylvania, many of which were framed in imitation of the Canadian laws, the most noteworthy feature of which is the provision giving a position to the homœopaths and eclectics on the board of examiners.

From the examples already given some estimate may be made of the effectiveness of these laws. Their advocates do not pretend that they are without defects. They have been chiefly successful in driving peripatetic practitioners out of the State, in checking the sale of bogus diplomas, and in making the struggle for existence of the more notorious form of quackery uncertain and difficult.

On the other hand, these laws are not without grave defects. They have been chiefly objected to as partaking of the character of class legislation, and it is difficult to persuade our legislators that they are not framed in the sole interest of the medical profession. They are unpopular with the public, as they interfere with the right of every American citizen to exercise perfect freedom in the selection of his medical adviser. To the mind of the educated physician the passage of such a law involves serious difficulties, to overcome which sacrifices must be conceded which imperil, if they do not completely counterbalance, the advantages which are supposed to be derived from it. Concessions must be made to, and the protecting influence of the law must be extended over, some of the very classes of practitioners it is proposed to reform. The States already recognize as “educated physicians” numerous sects professing belief in certain special systems of medicine, such as the eclectic, the homœopathic, the Thomsonian, the medico-botanical, etc., and are quite ready to admit into this category other practitioners without special forms of belief, or indeed of any particular education, who form themselves into associations with high-sounding titles, prepared ostentatiously to acknowledge the benefits of such a law and to claim its protection. In addition to all these there exist in this State the magnetic, the spiritualist, and medico-religious practitioners, who have a large and earnest following, whose claims would not be ignored by a committee having the bill in charge. In view of such possibilities the society may do well to ask itself whether it is fulfilling its duties to the public to advise the enactment of a law which will “galvanize into an appearance of temporary activity” numerous sects of varying degrees of vitality, or give even official recognition to that class of “healers” which constitutes a very large “part of the thing to be reformed.”

It will be argued that these objections in no way invalidate the main feature of the bill, which establishes a standard of education to be secured by specified examination. To which it might be said in reply that no law could be passed, the penalties for non-compliance with which could not be evaded, and that we should thus be saddled with an act uncertain in its restraining, but quite positive in its protective, influences upon the “irregulars.” Those who were of the latter opinion might take the view that the society would more appropriately fulfill its mission by maintaining a high standard of education among those it admits to membership, thus making the contrast between the educated physician and irregular practitioner as striking as possible, than to busy itself with special protective legislation for practice and fees.

These are some of the aspects of a question the advocates of which, in no way discouraged by defeat, will urge again upon the Legislature at an early day. Upon such an important subject it will be advisable for the society to have an opinion, whether it may think best to take an active part in the discussion or not.

In this connection I would call your attention to a movement which is now going on within the society, and may lead eventually to important results.

In the numerous discussions which have taken place in recent years upon the question of admitting female practitioners to the society, attention has frequently been drawn to the fact that no uniformity exists in the examinations conducted by the different boards of Censors throughout the State, and that the various boards have no means of communicating with one another, or of comparing their work. An individual rejected by one of these boards may present himself for examination at some distant portion of the State, and be made a member of the society. Many of the boards, it was found recently, were ignorant of certain changes in the laws of the society. It is proposed that each board should hereafter report to the secretary of the society the names of all individuals who have failed to pass. It has also been suggested that a central committee be appointed to furnish certain information to the various boards, and that meetings of this committee, with delegates from each board, should be held at stated intervals. We have here the elements of an “educational section” of the society, from which a vast amount of valuable and interesting work might emanate, and to which might safely be intrusted the task of elaborating a plan which might offer a solution of some of the difficulties attending attempts to restrict the work of irregular practitioners. The society should not forget that it is through the efforts of some of its members that one of the most interesting experiments in medical education in this country is now being successfully completed; that the medical prestige of Massachusetts is to-day superior to that of any other State in the Union; and that any such work which should emanate from medical men in this State would be regarded as valuable authority. The subject is one of the important questions of the day; a free discussion by members of the society could hurt no one, and might be productive of valuable contributions to the cause.

The position of our society toward the treatment of insanity has always been one of cordial cooperation with those gentlemen of our profession who have devoted themselves to the difficult and troublesome duties of asylum life in caring for the insane. The century’s work in that respect is one of which we may be justly proud; our hospitals are among the few in the country which are free from political influences, and, through our distinguished members, Drs. Wyman and Bell, Massachusetts has stamped its mark upon the treatment of insanity throughout the country, and indeed to a very great extent in the Old World, through the efforts of Miss Dix, who has carried our humane methods to England, Scotland, and, in a less degree, to the continent of Europe. More recently the society has shown a closer interest in insanity, as indicated by its investigations in regard to commitments to asylums, and by the fact that twelve of our number have taken upon themselves the arduous duty of being consulting physicians of the Danvers Hospital, two visiting together each month at least once. It is evident that it is not practicable to have visiting physicians in charge of insane asylums, while it is desirable to bring the interest of the profession to bear upon that important matter.

With the views of insanity held at the present time, somewhat different from those prevailing a quarter of a century ago, the work of the physician in general practice has widened as regards his relations to people suffering from mental disease. As it becomes better known, and is held more and more by the community to be simply a disease, more or less like other diseases, it will, whether treated in insane asylums or not, be each year to a greater extent advised upon by the practicing physician. The character of our institutions, too, must be changed to a considerable degree from being receptacles or boarding-houses for all kinds of mental deficiency to asylums for the incurable and hospitals in the strict sense of the word, with every appliance which art and science can afford for remedial treatment. In the discussion of this vast question our society can cooperate with the officers of the hospitals for the insane, and an enlightened public opinion which demands more scientific work, and help to place the whole subject in a better light before the community by increasing confidence where there is now unmerited distrust, by showing the falseness of exaggerated complaints, and by assisting all real progress and wise reform. The society is in a position to assist in guiding the legislation regarding insanity in a judicious direction, to help form opinion upon the best methods of improving our hospitals for the insane, and to raise the standard of professional and public knowledge of the causes and prevention of that obscure disease.

The unsatisfactory state of the laws relating to medical expert testimony has from time to time caused much discussion in this State, and cannot fail to have impressed every member of the society who has been called to the witness stand. It is, to say the least, an incongruity that his opinion, which, like that of the presiding officer, is judicial in its character, should be paid for, and to a certain extent controlled, by one of the parties to the suit, and that there should be no discrimination exercised in. the selection of individuals who are expected to give testimony of a high scientific value. The abuses of this system are so many-sided, and such striking examples have occurred lately, that it is hardly necessary to draw your attention to them in detail.

In 1868 our society united with the American Academy of Arts and Sciences to present to the Legislature the draft of a law prepared by the late Hon. Emory Washburne, giving discretion to the court to appoint and require the attendance of one or more persons to be examined as experts. It was referred to the judiciary committee, but never came to light afterwards. A committee of the Massachusetts Medico-Legal Society, of which the attorney-general of the State was chairman, has within a year prepared the draft of a bill for legislative action. This bill provides “that in any action, suit, or proceeding, civil or criminal, in which the testimony of a medical expert witness is desired,” the parties must make another agreement upon a suitable person, or if they fail to agree the court must appoint the same, upon whom a subpoena will then be served, and whose expenses will be paid by the court, the defeated party being liable to refund the amount. The court may also call other witnesses if it so desires, and in a criminal case the defendant is allowed additional witnesses at his own cost.

At a meeting of the Boston Society for Medical Improvement, held last autumn, a committee was appointed to cooperate with other societies in this matter, and it was then suggested that the Massachusetts Medical Society possesses the element of organization out of which some plan might be evolved which should serve to determine more definitely the status of the medical expert.

It appears that the English method is open to abuse, like our own, while in Germany the law provides for official experts, and under the French plan the choice of the expert is left to the discretion of the court. In the last two countries, the medico-legal results are said to be admirable, and in striking contrast to the results with which we are familiar.

In connection with this subject, I would call the attention of the society to the extraordinary facility with which suits for malpractice are brought against reputable physicians, a form of business enterprise which, I regret to say, lawyers of the highest respect ability in this city consider as perfectly legitimate work to be engaged in. Nothing is better calculated to bring the majesty of the law into disrepute than a system which permits, under the guise of legal processes, a rascally attack upon the pockets of a hardworking and innocent man, while the blunders of the ignorant quack are allowed to go unpunished. It has been suggested that judges should exercise some right of supervision, so that fraudulent suits should be prevented from obtaining a place on the dockets, or that all costs, including the defendant's counsel fees, should be paid by the plaintiff if he loses his case. The society would do well to urge some such restrictive action.

The labors of those engaged in the department of experimental medicine have fortunately not yet been interfered with by the anti-vivisectionists. The great importance of this work in enabling us to acquire more accurate knowledge of the laws of health and disease is doubtless duly appreciated by members of the society. The study of medical science is still in its infancy in this country, but a great deal of valuable original work has already been done, and the profession has reason to be proud of its record in this department. Still a crusade, such as has swept over England, would strike a severe blow at further progress in medical knowledge. The public should be taught that this is a legitimate field of study, and one which has wrested from nature many valuable secrets. The Medical Society of the State of New York has set a good example to other societies in protecting her scientific men from attempts to interfere with their work by legislation. Repeated efforts to obtain such legislation have been foiled by the agency of individual members, who have promptly put their senators and representatives in possession of the facts of the case.

It has been the policy of the society of late years to offer, in addition to its time-honored certificate of membership, special advantages to each Fellow individually. The wisdom of this plan is shown in the thriving character of such associations as adopt the expedient. Volumes of Transactions, although extremely valuable in preserving an historical record of the society's work, cannot be placed in this category. On the other hand, a medical periodical included as part of the returns to be obtained from the annual assessment is something tangible, which becomes a connecting link to those members who, owing to circumstances, are unable to take an active part in the work of the society. The annual dinner has also proved a most useful feature in bringing together a larger number of members at one gathering than any other society can boast of, and in securing prompt payment of the society's dues. The excellent retrospect of medical science distributed to each member has been a popular and useful experiment. It gives to the busy member of the society valuable hints for use in practice, and affords interesting reading at the same time to the literary and scientific man. Like the patent food or nutritive enema, it administers its pabulum in a convenient and condensed form to those whose minds are intolerant of the more tedious processes by which the original article is usually administered.

The suggestion has, however, been made from several quarters, particularly from districts which depend chiefly upon the publications which the society offers, that a weekly periodical would be a more satisfactory form of journal, and that the patronage of native work would be more in keeping with the spirit and traditions of the society. The “semi-annual” and the “quarterly” are types of periodical literature which are gradually becoming extinct. Science moves too rapidly, and is too impatient of delay, to use such ponderous vehicles. A vigorous and progressive association like our own is hardly keeping up with the times in contenting itself with receiving the work of others at second hand and at long intervals, while it allows its own to be hidden in the volumes of Transactions. The same arguments which have been so frequently urged in behalf of a weekly journal for our national association are equally true of each state society. Were a group of States like those of New England to unite upon a common medium of inter-communication, the stimulus to society work of all kinds would be immense, and the advantages of cooperation would bring with it great power. It will be a glorious day, both for medical societies and medical literature, in this country, when this principle becomes recognized.

There is one more topic to which it might be appropriate to allude on such an occasion as this, and that is the manner of conducting our annual meetings. In former years one day was considered sufficient to accomplish all the work the society had to do; but since 1866 a second has been added. It is a frequent criticism that annual gatherings of medical men rarely accomplish any really useful scientific work, being chiefly of a social character. So far as the strictly literary work of the meetings is concerned this is frequently true, but the metropolis at which the gatherings are held becomes for the time being a medical exhibition on a large scale. The hospitals, schools, and museums, and medical institutions of all kinds, are prepared for the occasion. New inventions, new methods of management, groups of interesting cases, are shown in this way, and any new surgical operation or scientific discovery can thus be brought publicly before the profession. At the last two meetings an innovation has been introduced in the shape of an exhibition of drugs, instruments, and medical books in a room adjacent to the hall of the meeting. As a convenience to visiting members this has proved satisfactory; but a more interesting form of exhibit would be a collection of all apparatus and inventions devised by members of the society. The success of the historical collection of instruments and books this year will, I think, be sufficiently great to suggest a continuance of exhibitions in which members participate. That portion of the meeting which needs life infused into it, and into which at this centennial period it would be most appropriate to introduce a new order of things, is the literary work of the society on the first day. Many excellent papers are annually read, but little encouragement is given to the readers to repeat the experiment. Such an exercise without an accompanying debate is a meaningless, and I might venture to add almost useless, performance. The meeting is thinly attended, and the exercises languish. Such was the condition of most society meetings in this neighborhood a few years since, but a new spirit has been infused into our Boston societies, which it is to be hoped has not been made at the expense of the parent society. The secret of success lies in the care with which the work of the meeting is cut out beforehand. Nothing should be left to chance, with all its terrible possibilities; but a debate, participated in by men whom all are anxious to hear, should be organized early in the season, giving ample time for preparations. Important questions of the day might get the benefit of careful study from our best men, and we might aspire to produce in this way some original work.

The formation of the Medico-Legal Society, which has proved so valuable an adjunct to our annual meetings, shows how useful a body an organization designed for special work may become. As the wants of any special department of medicine became urgent in the State, similar societies might be formed, which might or might not be sections of the Massachusetts Medical Society.

The educational section has already been alluded to, and would come next in order. Some such plan of gradual development would be preferable to assigning all work to special sections, which, so far as I am aware, state societies have not yet attempted. Departments which might be contemplated in the near future would embrace those branches of state medicine which relate to insanity and to hygiene, bodies which medical officials in the State would naturally turn to for advice or support, and from which, did they exist to-day, work of great value to the State might emanate.

I have thus attempted to sketch the plan of organization of our society from its beginning, and to offer a few suggestions for work in the future. When we compare it with some of the representative bodies of the world, the results of a century's growth are certainly gratifying. In pausing at the first great halting place, to look back through one hundred years, the eye sweeps over a period of unbroken prosperity, unmarred by disputes or factions. In spite of the various waves of delusion or pseudo-science which have passed over the community during that period, the society has maintained an unbroken front, and has always rallied round the flag of truth and integrity. Its attitude has been the only one which a truly scientific body could take. It has been the champion of perfect liberty of action to all, but has withheld the hand of fellowship from those who would deny this boon to others, or would seek to enchain science with the manacles of theory or deceit.

The veterans to whom much of this credit is due are passing away, and younger heads and hands are coming forward. In behalf of the latter, I would say that we assume the trust with a full sense of its responsibility, encouraged by the hope that the century which now opens before us may be as full of harmony and prosperity for our society as the one which has passed away.

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