from circumstances of a personal nature which rendered it perfectly natural, exclaimed, "Who reads an American book?" This has been over and over again quoted as a fair expression of the estimate in England of our bibliography. It should never be quoted except to add that its author was more unjust to his own countrymen than to us. All who are familiar with the medical periodical literature of Great Britain must have been impressed with the great candor and consideration generally shown in reviews and notices of American works. Not unfrequently these have received far more approbation abroad than at home. This is certainly a fitting occasion to declare that there is no ground to impute a prejudice, either in Great Britain or any other country, against our national literature.

That our works and periodical literature have in general a practical character is readily accounted for by our youth as a nation, and the rapid extension of population over a vast continent. With increase of years, and the altered circumstances incident thereto, our future in medical literature, it may safely be predicted, will show a wider scope. Thus far in our progress, the pressing claim upon our writers has been the wants of our widely separated brethren as regards qualification for the active duties of the practitioner.

The statement just made suggests the leading characteristic of our medical schools, namely, practical instruction. I shall not encroach upon the ground of the distinguished physician who is to address us on the subject of American medical education. He may, perhaps, point out defects in our educational institutions. That there are defects, is not to be denied. But, that we may not do injustice to our predecessors and our contemporaries, let it be considered how peculiar is the situation of the profession of this country in this regard. The whole responsibility for medical education, inclusive of the means for its promotion, rests, for the most part, with the Profession. Medical schools are without the jurisdiction of the general government, and our numerous States can only control, of course, those within their respective borders. Hence, uniformity throughout the country in legislating in behalf of medical education is impracticable. Legislative provisions for the increase and diffusion of medical knowledge are apt to be regarded in the light of appropriations for the benefit of a particular class of citizens. A diploma or a license to practise medicine from some legally authorized body is easily obtained, and the law practically places no obstacle in the way of practising without either. Now, in view of these facts, which are, of course, familiar to all of us, how are we to explain the annual gatherings of medical students and practitioners in large numbers in Philadelphia, New York, and other cities, many coming from distant parts of the Union, incurring expenses which often involve much exertion and selfdenial? What other explanation is there than, first, that certain of our medical schools afford large opportunities in the way of practical instruction; and, second, that there is a wide-spread yearning for these opportunities simply on account of their intrinsic worth? Have we not here the evidence of a spirit of progress in both teachers and pupils, which is creditable to the past and present, as, also, an earnest for the future? Let us strive to remove defects, to correct abuses, and to improve, as fast as practicable, our system of instruction; but let us not be led into a disparagement of what has been done, and is now being done, in behalf of medical education.

A few words in conclusion, concerning characteristics which relate to medical ethics. At the Convention held in 1847, resulting in the orga nization of the American Medical Association, a code of ethics was adopted, and it has since been formally recognized as having binding force upon members of state and local societies throughout the Union. This code embodies rules which were in accordance with the usages of worthy members of the profession in this country, and with established ethical principles in other countries. It defines simply and clearly the line of conduct to be followed in the relations of medical men to each other and the profession at large, to their patients, to the public, and to those who, adopting a practice based on an exclusive dogma, or from unworthy acts, are not to be considered as professional brethren. This code has remained unaltered and with undiminished force for more than a quarter of a century. I state this fact as a characteristic which reflects honor on the representatives of American Medicine. I claim, in behalf of the Medical Profession of the United States, that the great majority of its members have been loyal to the code of ethics. With no penalty for violations of ethical rules beyond the loss of professional fellowship, a penalty which may be made subservient to selfish advantage, loyalty is secured by motives of self-respect, and regard for the power of the Profession. It may perhaps be claimed that in no other country is the line dividing legitimate and illegitimate medicine more distinctly defined than with us; and nowhere are instances of affiliation with irregular practitioners more infrequent. The same may perhaps be said of the number of those who, having once been in respectable professional standing, have yielded to the temptation of originating secret nostrums and patenting remedies or inventions. These characteristics are consistent with the fact that in no other country does the Profession of Medicine hold a higher social position or exert a greater public influence than in these United States of America.

We

Gentlemen, Members of the International Medical Congress: At this our Centennial Anniversary it has seemed to me appropriate to survey "Medicine and Medical Progress in the United States" from the points of view which excite feelings of gratification, hope, and faith. should by no means shut our eyes to errors, defects, and short-comings; but there are other occasions more suitable for regarding these. The history of American Medicine for the past century contains much that we may rightly be proud of; we have no reason to be ashamed of its present condition, and need we doubt that the spirit of progress which has thus far guided it, will lead onward to the fulfilment of a glorious destiny!

ADDRESS ON HYGIENE AND PREVENTIVE MEDICINE.

BY

HENRY I. BOWDITCH, M.D.,

PRESIDENT OF THE STATE BOARD OF HEALTH OF MASSACHUSETTS.

GENTLEMEN OF THE INTERNATIONAL MEDICAL CONGRESS:

I HAVE been requested to speak to you on Public Hygiene and its great resultant, State Preventive Medicine, as it appears to an observer looking back upon the Centennial Period now just closing.

As a measure of vital importance to the well-being of any community, and, as such, worthy to be cheerfully and amply sustained by great cities and States, Public Hygiene, as we now understand that term, has, till within a very short time, been wofully neglected, save when, under the stimulus of some great and terrible epidemic, frantic but temporary ef forts have been made to stay the plague by Hygienic or by other means. Of late, however, a new and better era seems opening to our view, and STATE PREVENTIVE MEDICINE affords us higher hopes for all coming time. To this last, this noblest phase of Public Hygiene, its very gradual evolution out of the dogmatism and skepticism of the past, its present status, our duties relative thereto, and our golden hopes for its future, I crave your candid consideration during the brief hour I shall have the honor of addressing you. If, at the termination of my remarks, our foreign associates feel that I have given them but little information, and my countrymen find that I have said but little in praise of my country, one and all of you, I trust, will generously allow me the credit of having endeavored at least to speak the exact truth about the various States, and the United States as a Nation, in their relation to these matters. May I dare to hope that the plain unvarnished story of our present condition and short-comings, in regard to practical public hygiene, may do something to stimulate each State and the United States governments, to do more thoroughly the plain duties that lie open before them?

Before laying down the propositions I intend to defend, let me say we cannot, in the consideration of them, confine our view simply to this country, but must frequently refer to the men and ideas of other countries, as well as to those of our own.

And let me add that in citing the names of men who have been prominent here or elsewhere, I shall do so without intending either praise or blame, but simply as those of illustrious representatives of great systems of medicine or of wide currents of thought, upon which the greater part of mankind has been borne almost unconsciously along.

NATURAL DIVISIONS OF THE CENTENNIAL PERIOD.

In its Medical and Social ideas, the past centenary easily divides itself into three unequal epochs, viz.: I. From 1776 to 1832, the era of theory and of dogmatism; II. From 1832 to 1869, or that of strict observation,

and of bold, often reckless, skepticism; III. From 1869 to 1876, which is destined to continue and progress while the nation itself lives, the noblest and most beneficent of all, viz., that in which the profession, joining heartily with the laity and aided by the material and intellectual resources of great States, will study to unravel the primal causes of all disease with the object of preventing it. It is the epoch of State Preventive Medicine.

FIRST EPOCH, OR THAT OF MEDICAL SYSTEM-MAKING, FILLED WITH AN OVERWEENING CONFIDENCE IN OUR ART, WITH LITTLE OR NO FAITH IN THE VIS MEDICATRIX NATURE.

(From 1776 to 1832, or thereabouts.)

The influences which governed this period and the previous centuries, may be briefly sketched as follows: The illustrious Boerhaave began to enunciate his doctrines of disease at Leyden in 1701. His doctrines held sway in America until about 1765, or ten years before the opening of our centennial period. Following closely after him came Hoffmann, Cullen, Brown, and Darwin, and each with his own peculiar system.

Our ingenious and renowned countryman, Benjamin Rush, in 1790, proclaimed his own idea, viz., that a convulsive motion of the arteries is the proximate cause of all fevers, however different the causes may be. Benjamin Rush was one of the most noteworthy men this centenary has produced, and as he had more influence than any other one person upon medical opinion during the first epoch; as he is called by one of his admirers "the American Sydenham," it seems to me not improper that I should on this occasion mention some facts of his life. He was born Dec. 24, 1745, on his father's plantation, fourteen miles from Philadelphia: consequently he was just entering the prime of manhood in 1776. Seven years before that, at the early age of twenty-four, he had been appointed Professor of Chemistry in the University of Pennsylvania.

During the Revolutionary war he resigned this professorship, and was made Medical Director of the Middle Department of the Continental Army. In 1789 he resumed his professorship of chemistry, and in October of that year became Professor of the Theory and Practice of Medicine, which office he held until his death in 1813. During all these years he energetically and ably defended his system, as he had previously upheld Cullen's. He has left accounts of various epidemics of yellow fever and other observations and essays, which are valuable as records of the period and as evidences of his intellectual and moral worth. Ile was essentially a medical system-maker like his predecessors. He believed fully in heroic remedies, and rather scoffed at Nature's influence in disease. His pupils spread themselves over some of the Eastern but more over the Middle, Western, and Southern States, carrying with them not only the wisdom but the errors of their great master. He thus had vast influence on the medical ideas of the country. This becomes still more evident when we remember that he held the chief professorship in the foremost medical school in the Union, and that, towards the end of his career, the number of students that listened to his eloquent and per

1 Rush's Med. Inquiries and Observations, Philadelphia, vol. iii. p. 11.

suasive tongue, amounted to about four hundred, annually drawn to Philadelphia from every part of the country.

The reputation of our profession among the more intelligent of the laity, when Dr. Rush was in his full glory, is brought out in the following extract from a letter from Thomas Jefferson to his friend Dr. Wistar in 1807. He writes, "I have myself lived long enough to see the fashions of Hoffmann, Boerhaave, Stahl, and Brown succeed one another like the shifting figures of a magic lantern, and their fancies like the dresses of the doll-babies from Paris; becoming from their novelty the vogue of the day, and yielding to the next novelty their ephemeral favor." We may well fear that Mr. Jefferson's opinion of our profession was not much improved when Dr. Rush dogmatically proclaimed, during a heated discussion with some physicians of Philadelphia, that the time must and will come when the general use of calomel, jalap, and of the lancet without a physician's advice, will be considered "aniong the most essential articles of the knowledge and the rights of man"!

But Dr. Rush's theory and dogmatism were destined to fall under the influence of the fascinating theories of Broussais. Broussais was born in 1772, when Rush had already given evidence of his great powers as a teacher. This great Frenchman died in 1838, after his authority, which had been world-wide, had begun to decline. Broussaism spread widely in America, but less in New England, which had been trained more to close observation under the great masters in medicine, Dr. E. A. Holyoke, Dr. James Jackson, and others, than it did in the Middle, Western, and Southern States. In or about 1832, the system began to fall in America, as it had been previously falling in Europe. With its fall our first epoch terminates. The whole tenor of medical opinion during the period, as you readily perceive, with its theories and systems concocted in great minds, was not in the smallest degree suited to the growth of State Preventive Medicine.

SECOND EPOCH; OR THAT OF OBSERVATION, AND ACCURATE RECORDING AND SUBSEQUENT ANALYSIS OF FACTS; WITH AN EXTREME CONFIDENCE IN NATURE'S POWER IN DISEASE; A CORRESPONDING SKEPTICISM IN REGARD TO THE USE OF DRUGS; AND, FINALLY, DIM PRESAGES OF PREVENTIVE MEDICINE.

(From 1832 to 1869.)

The second epoch presents characteristics precisely the reverse of the first. Louis and his numerical method stand prominent in it. Louis may be called the lineal scientific descendant of such men as William and John Hunter, Morgagni, etc. His nature rebelled against the dogmatism of the past, unsupported as it was by well-ascertained and recorded facts. You all know the great and wide-spread influence of his works in Europe; Broussaism fell before them. The epoch in America commenced when Dr. Gerhard, of Philadelphia, and Dr. James Jackson, Jr., of Boston, and other pupils of the observation school, returned to America. Drs. Gerhard and Jackson had high mental powers finely cultivated. Both came back devoted friends, and admirers of Louis as a man and as a medical reformer. They were full of the new ideas, and enthusiastic defenders and expounders of them. The influence of these

'Works of Thomas Jefferson, Washington, 1854, vol. ix. p. 107.