But when it comes to substances alien to the healthy system, which never belong to it as normal constituents, the case is very different. There is a presumption against putting lead or arsenic into the human body, as against putting them into plants, because they do not belong there, any more than pounded glass, which, it is said, used to be given as a poison. The same thing is true of mercury and silver. What becomes of these alien substances after they get into the system we cannot always tell. But in the case of silver, from the accident of its changing color under the influence of light, we do know what happens. It is thrown out, in part at least, under the epidermis, and there it remains to the patient's dying day. This is a striking illustration of the difficulty which the system finds in dealing with non-assimilable elements, and justifies in some measure the vulgar prejudice against mineral poisons.
I trust the youngest student on these benches will not commit the childish error of confounding a presumption against a particular class of agents with a condemnation of them. Mercury, for instance, is alien to the system, and eminently disturbing in its influence. Yet its efficacy in certain forms of specific disease is acknowledged by all but the most sceptical theorists. Even the esprit moqueur of Ricord, the Voltaire of pelvic literature, submits to the time-honored constitutional authority of this great panacea in the class of cases to which he has devoted his brilliant intelligence. Still, there is no telling what evils have arisen from the abuse of this mineral. Dr. Armstrong long ago pointed out some of them, and they have become matters of common notoriety. I am pleased, therefore, when I find so able and experienced a practitioner as Dr. Williams of this city proving that iritis is best treated without mercury, and Dr. Vanderpoel showing the same thing to be true for pericarditis.
Whatever elements nature does not introduce into vegetables, the natural food of all animal life,—directly of herbivorous, indirectly of carnivorous animals,—are to be regarded with suspicion. Arsenic-eating may seem to improve the condition of horses for a time,—and even of human beings, if Tschudi's stories can be trusted,—but it soon appears that its alien qualities are at war with the animal organization. So of copper, antimony, and other non-alimentary simple substances; everyone of them is an intruder in the living system, as much as a constable would be, quartered in our household. This does not mean that they may not, any of them, be called in for a special need, as we send for the constable when we have good reason to think we have a thief under our roof; but a man's body is his castle, as well as his house, and the presumption is that we are to keep our alimentary doors bolted against these perturbing agents.
Now the feeling is very apt to be just contrary to this. The habit has been very general with well-taught practitioners, to have recourse to the introduction of these alien elements into the system on the occasion of any slight disturbance. The tongue was a little coated, and mercury must be given; the skin was a little dry, and the patient must take antimony. It was like sending for the constable and the posse comitatus when there is only a carpet to shake or a refuse-barrel to empty. [Dr. James Johnson advises persons not ailing to take five grains of blue pill with one or two of aloes twice a week for three or four months in the year, with half a pint of compound decoction of sarsaparilla every day for the same period, to preserve health and prolong life. Pract. Treatise on Dis. of Liver, etc. p. 272.] The constitution bears slow poisoning a great deal better than might be expected; yet the most intelligent men in the profession have gradually got out of the habit of prescribing these powerful alien substances in the old routine way. Mr. Metcalf will tell you how much more sparingly they are given by our practitioners at the present time, than when he first inaugurated the new era of pharmacy among us. Still, the presumption in favor of poisoning out every spontaneous reaction of outraged nature is not extinct in those who are trusted with the lives of their fellow-citizens. "On examining the file of prescriptions at the hospital, I discovered that they were rudely written, and indicated a treatment, as they consisted chiefly of tartar emetic, ipecacuanha, and epsom salts, hardly favorable to the cure of the prevailing diarrhoea and dysenteries." In a report of a poisoning case now on trial, where we are told that arsenic enough was found in the stomach to produce death in twenty-four hours, the patient is said to have been treated by arsenic, phosphorus, bryonia, aconite, nux vomica, and muriatic acid,—by a practitioner of what school it may be imagined.
The traditional idea of always poisoning out disease, as we smoke out vermin, is now seeking its last refuge behind the wooden cannon and painted port-holes of that unblushing system of false scientific pretences which I do not care to name in a discourse addressed to an audience devoted to the study of the laws of nature in the light of the laws of evidence. It is extraordinary to observe that the system which, by its reducing medicine to a name and a farce, has accustomed all who have sense enough to see through its thin artifices to the idea that diseases get well without being "cured," should now be the main support of the tottering poison-cure doctrine. It has unquestionably helped to teach wise people that nature heals most diseases without help from pharmaceutic art, but it continues to persuade fools that art can arrest them all with its specifics.
It is worse than useless to attempt in any way to check the freest expression of opinion as to the efficacy of any or all of the "heroic" means of treatment employed by practitioners of different schools and periods. Medical experience is a great thing, but we must not forget that there is a higher experience, which tries its results in a court of a still larger jurisdiction; that, namely, in which the laws of human belief are summoned to the witness-box, and obliged to testify to the sources of error which beset the medical practitioner. The verdict is as old as the father of medicine, who announces it in the words, "judgment is difficult." Physicians differed so in his time, that some denied that there was any such thing as an art of medicine.
One man's best remedies were held as mischievous by another. The art of healing was like soothsaying, so the common people said; "the same bird was lucky or unlucky, according as he flew to the right or left."
The practice of medicine has undergone great changes within the period of my own observation. Venesection, for instance, has so far gone out of fashion, that, as I am told by residents of the New York Bellevue and the Massachusetts General Hospitals, it is almost obsolete in these institutions, at least in medical practice. The old Brunonian stimulating treatment has come into vogue again in the practice of Dr. Todd and his followers. The compounds of mercury have yielded their place as drugs of all work, and specifics for that very frequent subjective complaint, nescio quid faciam,—to compounds of iodine. [Sir Astley Cooper has the boldness,—or honesty,—to speak of medicines which "are given as much to assist the medical man as his patient." Lectures (London, 1832), p. 14.] Opium is believed in, and quinine, and "rum," using that expressive monosyllable to mean all alcoholic cordials. If Moliere were writing now, instead of saignare, purgare, and the other, he would be more like to say, Stimulare, opium dare et potassio-iodizare.
I have been in relation successively with the English and American evacuant and alterative practice, in which calomel and antimony figured so largely that, as you may see in Dr. Jackson's last "Letter," Dr. Holyoke, a good representative of sterling old-fashioned medical art, counted them with opium and Peruvian bark as his chief remedies; with the moderately expectant practice of Louis; the blood-letting "coup sur coup" of Bouillaud; the contra-stimulant method of Rasori and his followers; the anti-irritant system of Broussais, with its leeching and gum-water; I have heard from our own students of the simple opium practice of the renowned German teacher, Oppolzer; and now I find the medical community brought round by the revolving cycle of opinion to that same old plan of treatment which John Brown taught in Edinburgh in the last quarter of the last century, and Miner and Tully fiercely advocated among ourselves in the early years of the present. The worthy physicians last mentioned, and their antagonist Dr. Gallup, used stronger language than we of these degenerate days permit ourselves. "The lancet is a weapon which annually slays more than the sword," says Dr. Tully. "It is probable that, for forty years past, opium and its preparations have done seven times the injury they have rendered benefit, on the great scale of the world," says Dr. Gallup.
What is the meaning of these perpetual changes and conflicts of medical opinion and practice, from an early antiquity to our own time? Simply this: all "methods" of treatment end in disappointment of those extravagant expectations which men are wont to entertain of medical art. The bills of mortality are more obviously affected by drainage, than by this or that method of practice. The insurance companies do not commonly charge a different percentage on the lives of the patients of this or that physician. In the course of a generation, more or less, physicians themselves are liable to get tired of a practice which has so little effect upon the average movement of vital decomposition. Then they are ready for a change, even if it were back again to a method which has already been tried, and found wanting.
Our practitioners, or many of them, have got back to the ways of old Dr. Samuel Danforth, who, as it is well known, had strong objections to the use of the lancet. By and by a new reputation will be made by some discontented practitioner, who, tired of seeing patients die with their skins full of whiskey and their brains muddy with opium, returns to a bold antiphlogistic treatment, and has the luck to see a few patients of note get well under it. So of the remedies which have gone out of fashion and been superseded by others. It can hardly be doubted that they will come into vogue again, more or less extensively, under the influence of that irresistible demand for change just referred to.
Then will come the usual talk about a change in the character of disease, which has about as much meaning as that concerning "old-fashioned snow-storms." "Epidemic constitutions" of disease mean something, no doubt; a great deal as applied to malarious affections; but that the whole type of diseases undergoes such changes that the practice must be reversed from depleting to stimulating, and vice versa, is much less likely than that methods of treatment go out of fashion and come in again. If there is any disease which claims its percentage with reasonable uniformity, it is phthisis. Yet I remember that the reverend and venerable Dr. Prince of Salem told me one Commencement day, as I was jogging along towards Cambridge with him, that he recollected the time when that disease was hardly hardly known; and in confirmation of his statement mentioned a case in which it was told as a great event, that somebody down on "the Cape" had died of "a consumption." This story does not sound probable to myself, as I repeat it, yet I assure you it is true, and it shows how cautiously we must receive all popular stories of great changes in the habits of disease.
Is there no progress, then, but do we return to the same beliefs and practices which our forefathers wore out and threw away? I trust and believe that there is a real progress. We may, for instance, return in a measure to the Brunonian stimulating system, but it must be in a modified way, for we cannot go back to the simple Brunonian pathology, since we have learned too much of diseased action to accept its convenient dualism. So of other doctrines, each new Avatar strips them of some of their old pretensions, until they take their fitting place at last, if they have any truth in them, or disappear, if they were mere phantasms of the imagination.
In the mean time, while medical theories are coming in and going out, there is a set of sensible men who are never run away with by them, but practise their art sagaciously and faithfully in much the same way from generation to generation. From the time of Hippocrates to that of our own medical patriarch, there has been an apostolic succession of wise and good practitioners. If you will look at the first aphorism of the ancient Master you will see that before all remedies he places the proper conduct of the patient and his attendants, and the fit ordering of all the conditions surrounding him. The class of practitioners I have referred to have always been the most faithful in attending to these points. No doubt they have sometimes prescribed unwisely, in compliance with the prejudices of their time, but they have grown wiser as they have grown older, and learned to trust more in nature and less in their plans of interference. I believe common opinion confirms Sir James Clark's observation to this effect.
The experience of the profession must, I think, run parallel with that of the wisest of its individual members. Each time a plan of treatment or a particular remedy comes up for trial, it is submitted to a sharper scrutiny. When Cullen wrote his Materia Medica, he had seriously to assail the practice of giving burnt toad, which was still countenanced by at least one medical authority of note. I have read recently in some medical journal, that an American practitioner, whose name is known to the country, is prescribing the hoof of a horse for epilepsy. It was doubtless suggested by that old fancy of wearing a portion of elk's hoof hung round the neck or in a ring, for this disease. But it is hard to persuade reasonable people to swallow the abominations of a former period. The evidence which satisfied Fernelius will not serve one of our hospital physicians.
In this way those articles of the Materia Medica which had nothing but loathsomeness to recommend them have been gradually dropped, and are not like to obtain any general favor again with civilized communities. The next culprits to be tried are the poisons. I have never been in the least sceptical as to the utility of some of them, when properly employed. Though I believe that at present, taking the world at large, and leaving out a few powerful agents of such immense value that they rank next to food in importance, the poisons prescribed for disease do more hurt than good, I have no doubt, and never professed to have any, that they do much good in prudent and instructed hands. But I am very willing to confess a great jealousy of many agents, and I could almost wish to see the Materia Medica so classed as to call suspicion upon certain ones among them.
Thus the alien elements, those which do not properly enter into the composition of any living tissue, are the most to be suspected, —mercury, lead, antimony, silver, and the rest, for the reasons I have before mentioned. Even iodine, which, as it is found in certain plants, seems less remote from the animal tissues, gives unequivocal proofs from time to time that it is hostile to some portions of the glandular system.
There is, of course, less prima facie objection to those agents which consist of assimilable elements, such as are found making a part of healthy tissues. These are divisible into three classes,—foods, poisons, and inert, mostly because insoluble, substances. The food of one animal or of one human being is sometimes poison to another, and vice versa; inert substances may act mechanically, so as to produce the effect of poisons; but this division holds exactly enough for our purpose.
Strictly speaking, every poison consisting of assimilable elements may be considered as unwholesome food. It is rejected by the stomach, or it produces diarrhoea, or it causes vertigo or disturbance of the heart's action, or some other symptom for which the subject of it would consult the physician, if it came on from any other cause than taking it under the name of medicine. Yet portions of this unwholesome food which we call medicine, we have reason to believe, are assimilated; thus, castor-oil appears to be partially digested by infants, so that they require large doses to affect them medicinally. Even that deadliest of poisons, hydrocyanic acid, is probably assimilated, and helps to make living tissue, if it do not kill the patient, for the assimilable elements which it contains, given in the separate forms of amygdalin and emulsin, produce no disturbance, unless, as in Bernard's experiments, they are suffered to meet in the digestive organs. A medicine consisting of assimilable substances being then simply unwholesome food, we understand what is meant by those cumulative effects of such remedies often observed, as in the case of digitalis and strychnia. They are precisely similar to the cumulative effects of a salt diet in producing scurvy, or of spurred rye in producing dry gangrene. As the effects of such substances are a violence to the organs, we should exercise the same caution with regard to their use that we would exercise about any other kind of poisonous food,—partridges at certain seasons, for instance. Even where these poisonous kinds of food seem to be useful, we should still regard them with great jealousy. Digitalis lowers the pulse in febrile conditions. Veratrum viride does the same thing. How do we know that a rapid pulse is not a normal adjustment of nature to the condition it accompanies? Digitalis has gone out of favor; how sure are we that Veratrum viride will not be found to do more harm than good in a case of internal inflammation, taking the whole course of the disease into consideration? Think of the change of opinion with regard to the use of opium in delirium tremens (which you remember is sometimes called delirium vigilans), where it seemed so obviously indicated, since the publication of Dr. Ware's admirable essay. I respect the evidence of my contemporaries, but I cannot forget the sayings of the Father of medicine,—Ars longa, judicium diffcile.
I am not presuming to express an opinion concerning Veratrum viride, which was little heard of when I was still practising medicine. I am only appealing to that higher court of experience which sits in judgment on all decisions of the lower medical tribunals, and which requires more than one generation for its final verdict.
Once change the habit of mind so long prevalent among practitioners of medicine; once let it be everywhere understood that the presumption is in favor of food, and not of alien substances, of innocuous, and not of unwholesome food, for the sick; that this presumption requires very strong evidence in each particular case to overcome it; but that, when such evidence is afforded, the alien substance or the unwholesome food should be given boldly, in sufficient quantities, in the same spirit as that with which the surgeon lifts his knife against a patient,—that is, with the same reluctance and the same determination,—and I think we shall have and hear much less of charlatanism in and out of the profession. The disgrace of medicine has been that colossal system of self-deception, in obedience to which mines have been emptied of their cankering minerals, the vegetable kingdom robbed of all its noxious growths, the entrails of animals taxed for their impurities, the poison-bags of reptiles drained of their venom, and all the inconceivable abominations thus obtained thrust down the throats of human beings suffering from some fault of organization, nourishment, or vital stimulation.
Much as we have gained, we have not yet thoroughly shaken off the notion that poison is the natural food of disease, as wholesome aliment is the support of health. Cowper's lines, in "The Task," show the matter-of-course practice of his time:
"He does not scorn it, who has long endured
A fever's agonies, and fed on drugs."
Dr. Kimball of Lowell, who has been in the habit of seeing a great deal more of typhoid fever than most practitioners, and whose surgical exploits show him not to be wanting in boldness or enterprise, can tell you whether he finds it necessary to feed his patients on drugs or not. His experience is, I believe, that of the most enlightened and advanced portion of the profession; yet I think that even in typhoid fever, and certainly in many other complaints, the effects of ancient habits and prejudices may still be seen in the practice of some educated physicians.
To you, young men, it belongs to judge all that has gone before you. You come nearer to the great fathers of modern medicine than some of you imagine. Three of my own instructors attended Dr. Rush's Lectures. The illustrious Haller mentions Rush's inaugural thesis in his "Bibliotheca Anatomica;" and this same Haller, brought so close to us, tells us he remembers Ruysch, then an old man, and used to carry letters between him and Boerhaave. Look through the history of medicine from Boerhaave to this present day. You will see at once that medical doctrine and practice have undergone a long series of changes. You will see that the doctrine and practice of our own time must probably change in their turn, and that, if we can trust at all to the indications of their course, it will be in the direction of an improved hygiene and a simplified treatment. Especially will the old habit of violating the instincts of the sick give place to a judicious study of these same instincts. It will be found that bodily, like mental insanity, is best managed, for the most part, by natural soothing agencies. Two centuries ago there was a prescription for scurvy containing "stercoris taurini et anserini par, quantitas trium magnarum nucum," of the hell-broth containing which "guoties-cumque sitit oeger, large bibit." When I have recalled the humane common-sense of Captain Cook in the matter of preventing this disease; when I have heard my friend, Mr. Dana, describing the avidity with which the scurvy-stricken sailors snuffed up the earthy fragrance of fresh raw potatoes, the food which was to supply the elements wanting to their spongy tissues, I have recognized that the perfection of art is often a return to nature, and seen in this single instance the germ of innumerable beneficent future medical reforms.
I cannot help believing that medical curative treatment will by and by resolve itself in great measure into modifications of the food, swallowed and breathed, and of the natural stimuli, and that less will be expected from specifics and noxious disturbing agents, either alien or assimilable. The noted mineral-waters containing iron, sulphur, carbonic acid, supply nutritious or stimulating materials to the body as much as phosphate of lime and ammoniacal compounds do to the cereal plants. The effects of a milk and vegetable diet, of gluten bread in diabetes, of cod-liver oil in phthisis, even of such audacious innovations as the water-cure and the grape-cure, are only hints of what will be accomplished when we have learned to discover what organic elements are deficient or in excess in a case of chronic disease, and the best way of correcting the abnormal condition, just as an agriculturist ascertains the wants of his crops and modifies the composition of his soil. In acute febrile diseases we have long ago discovered that far above all drug-medication is the use of mild liquid diet in the period of excitement, and of stimulant and nutritious food in that of exhaustion. Hippocrates himself was as particular about his barley-ptisan as any Florence Nightingale of our time could be.
The generation to which you, who are just entering the profession, belong, will make a vast stride forward, as I believe, in the direction of treatment by natural rather than violent agencies. What is it that makes the reputation of Sydenham, as the chief of English physicians? His prescriptions consisted principally of simples. An aperient or an opiate, a "cardiac" or a tonic, may be commonly found in the midst of a somewhat fantastic miscellany of garden herbs. It was not by his pharmaceutic prescriptions that he gained his great name. It was by daring to order fresh air for small-pox patients, and riding on horseback for consumptives, in place of the smothering system, and the noxious and often loathsome rubbish of the established schools. Of course Sydenham was much abused by his contemporaries, as he frequently takes occasion to remind his reader. "I must needs conclude," he says, "either that I am void of merit, or that the candid and ingenuous part of mankind, who are formed with so excellent a temper of mind as to be no strangers to gratitude, make a very small part of the whole." If in the fearless pursuit of truth you should find the world as ungracious in the nineteenth century as he found it in the seventeenth, you may learn a lesson of self-reliance from another utterance of the same illustrious physician: "'T is none of my business to inquire what other persons think, but to establish my own observations; in order to which, I ask no favor of the reader but to peruse my writings with temper."
The physician has learned a great deal from the surgeon, who is naturally in advance of him, because he has a better opportunity of seeing the effects of his remedies. Let me shorten one of Ambroise Pare's stories for you. There had been a great victory at the pass of Susa, and they were riding into the city. The wounded cried out as the horses trampled them under their hoofs, which caused good Ambroise great pity, and made him wish himself back in Paris. Going into a stable he saw four dead soldiers, and three desperately wounded, placed with their backs against the wall. An old campaigner came up.—"Can these fellows get well?" he said. "No!" answered the surgeon. Thereupon, the old soldier walked up to them and cut all their throats, sweetly, and without wrath (doulcement et sans cholere). Ambroise told him he was a bad man to do such a thing. "I hope to God;" he said, "somebody will do as much for me if I ever get into such a scrape" (accoustre de telle facon). "I was not much salted in those days" (bien doux de sel), says Ambroise, "and little acquainted with the treatment of wounds." However, as he tells us, he proceeded to apply boiling oil of Sambuc (elder) after the approved fashion of the time,—with what torture to the patient may be guessed. At last his precious oil gave out, and he used instead an insignificant mixture of his own contrivance. He could not sleep that night for fear his patients who had not been scalded with the boiling oil would be poisoned by the gunpowder conveyed into their wounds by the balls. To his surprise, he found them much better than the others the next morning, and resolved never again to burn his patients with hot oil for gun-shot wounds.
This was the beginning, as nearly as we can fix it, of that reform which has introduced plain water-dressings in the place of the farrago of external applications which had been a source of profit to apothecaries and disgrace to art from, and before, the time when Pliny complained of them. A young surgeon who was at Sudley Church, laboring among the wounded of Bull Run, tells me they had nothing but water for dressing, and he (being also doux de sel) was astonished to see how well the wounds did under that simple treatment.
Let me here mention a fact or two which may be of use to some of you who mean to enter the public service. You will, as it seems, have gun-shot wounds almost exclusively to deal with. Three different surgeons, the one just mentioned and two who saw the wounded of Big Bethel, assured me that they found no sabre-cuts or bayonet wounds. It is the rifle-bullet from a safe distance which pierces the breasts of our soldiers, and not the gallant charge of broad platoons and sweeping squadrons, such as we have been in the habit of considering the chosen mode of warfare of ancient and modern chivalry. [Sir Charles James Napier had the same experience in Virginia in 1813. "Potomac. We have nasty sort of fighting here, amongst creeks and bushes, and lose men without show." "Yankee never shows himself, he keeps in the thickest wood, fires and runs off."—"These five thousand in the open field might be attacked, but behind works it would be throwing away lives." He calls it "an inglorious warfare,"—says one of the leaders is "a little deficient in gumption,"—but—still my opinion is, that if we tuck up our sleeves and lay our ears back we might thrash them; that is, if we caught them out of their trees, so as to slap at them with the bayonet."—Life, etc. vol. i. p. 218 et seq.]
Another fact parallels the story of the old campaigner, and may teach some of you caution in selecting your assistants. A chaplain told it to two of our officers personally known to myself. He overheard the examination of a man who wished to drive one of the "avalanche" wagons, as they call them. The man was asked if he knew how to deal with wounded men. "Oh yes," he answered; "if they're hit here," pointing to the abdomen, "knock 'em on the head,—they can't get well."
In art and outside of it you will meet the same barbarisms that Ambroise Pare met with,—for men differ less from century to century than we are apt to suppose; you will encounter the same opposition, if you attack any prevailing opinion, that Sydenham complained of. So far as possible, let not such experiences breed in you a contempt for those who are the subjects of folly or prejudice, or foster any love of dispute for its own sake. Should you become authors, express your opinions freely; defend them rarely. It is not often that an opinion is worth expressing, which cannot take care of itself. Opposition is the best mordant to fix the color of your thought in the general belief.
It is time to bring these crowded remarks to a close. The day has been when at the beginning of a course of Lectures I should have thought it fitting to exhort you to diligence and entire devotion to your tasks as students. It is not so now. The young man who has not heard the clarion-voices of honor and of duty now sounding throughout the land, will heed no word of mine. In the camp or the city, in the field or the hospital, under sheltering roof, or half-protecting canvas, or open sky, shedding our own blood or stanching that of our wounded defenders, students or teachers, whatever our calling and our ability, we belong, not to ourselves, but to our imperilled country, whose danger is our calamity, whose ruin would be our enslavement, whose rescue shall be our earthly salvation!
SCHOLASTIC AND BEDSIDE TEACHING.
An Introductory Lecture delivered before the Medical Class of Harvard
University, November 6, 1867.
The idea is entertained by some of our most sincere professional brethren, that to lengthen and multiply our Winter Lectures will be of necessity to advance the cause of medical education. It is a fair subject for consideration whether they do not overrate the relative importance of that particular mode of instruction which forms the larger part of these courses.
As this School could only lengthen its lecture term at the expense of its "Summer Session," in which more direct, personal, and familiar teaching takes the place of our academic discourses, and in which more time can be given to hospitals, infirmaries, and practical instruction in various important specialties, whatever might be gained, a good deal would certainly be lost in our case by the exchange.
The most essential part of a student's instruction is obtained, as I believe, not in the lecture-room, but at the bedside. Nothing seen there is lost; the rhythms of disease are learned by frequent repetition; its unforeseen occurrences stamp themselves indelibly in the memory. Before the student is aware of what he has acquired, he has learned the aspects and course and probable issue of the diseases he has seen with his teacher, and the proper mode of dealing with them, so far as his master knows it. On the other hand, our ex cathedra prelections have a strong tendency to run into details which, however interesting they may be to ourselves and a few of our more curious listeners, have nothing in them which will ever be of use to the student as a practitioner. It is a perfectly fair question whether I and some other American Professors do not teach quite enough that is useless already. Is it not well to remind the student from time to time that a physician's business is to avert disease, to heal the sick, to prolong life, and to diminish suffering? Is it not true that the young man of average ability will find it as much as he can do to fit himself for these simple duties? Is it not best to begin, at any rate, by making sure of such knowledge as he will require in his daily walk, by no means discouraging him from any study for which his genius fits him when he once feels that he has become master of his chosen art.
I know that many branches of science are of the greatest value as feeders of our medical reservoirs. But the practising physician's office is to draw the healing waters, and while he gives his time to this labor he can hardly be expected to explore all the sources that spread themselves over the wide domain of science. The traveller who would not drink of the Nile until he had tracked it to its parent lakes, would be like to die of thirst; and the medical practitioner who would not use the results of many laborers in other departments without sharing their special toils, would find life far too short and art immeasurably too long.
We owe much to Chemistry, one of the most captivating as well as important of studies; but the medical man must as a general rule content himself with a clear view of its principles and a limited acquaintance with its facts; such especially as are pertinent to his pursuits. I am in little danger of underrating Anatomy or Physiology; but as each of these branches splits up into specialties, any one of which may take up a scientific life-time, I would have them taught with a certain judgment and reserve, so that they shall not crowd the more immediately practical branches. So of all the other ancillary and auxiliary kinds of knowledge, I would have them strictly subordinated to that particular kind of knowledge for which the community looks to its medical advisers.
A medical school is not a scientific school, except just so far as medicine itself is a science. On the natural history side, medicine is a science; on the curative side, chiefly an art. This is implied in Hufeland's aphorism: "The physician must generalize the disease and individualize the patient."
The coordinated and classified results of empirical observation, in distinction from scientific experiment, have furnished almost all we know about food, the medicine of health, and medicine, the food of sickness. We eat the root of the Solanum tuberosum and throw away its fruit; we eat the fruit of the Solanum Lycopersicum and throw away its root. Nothing but vulgar experience has taught us to reject the potato ball and cook the tomato. So of most of our remedies. The subchloride of mercury, calomel, is the great British specific; the protochloride of mercury, corrosive sublimate, kills like arsenic, but no chemist could have told us it would be so.
From observations like these we can obtain certain principles from which we can argue deductively to facts of a like nature, but the process is limited, and we are suspicious of all reasoning in that direction applied to the processes of healthy and diseased life. We are continually appealing to special facts. We are willing to give Liebig's artificial milk when we cannot do better, but we watch the child anxiously whose wet-nurse is a chemist's pipkin. A pair of substantial mammary glands has the advantage over the two hemispheres of the most learned Professor's brain, in the art of compounding a nutritious fluid for infants.
The bedside is always the true centre of medical teaching. Certain branches must be taught in the lecture-room, and will necessarily involve a good deal that is not directly useful to the future practitioner. But the over ambitious and active student must not be led away by the seduction of knowledge for its own sake from his principal pursuit. The humble beginner, who is alarmed at the vast fields of knowledge opened to him, may be encouraged by the assurance that with a very slender provision of science, in distinction from practical skill, he may be a useful and acceptable member of the profession to which the health of the community is intrusted.
To those who are not to engage in practice, the various pursuits of science hardly require to be commended. Only they must not be disappointed if they find many subjects treated in our courses as a medical class requires, rather than as a scientific class would expect, that is, with special limitations and constant reference to practical ends. Fortunately they are within easy reach of the highest scientific instruction. The business of a school like this is to make useful working physicians, and to succeed in this it is almost as important not to overcrowd the mind of the pupil with merely curious knowledge as it is to store it with useful information.
In this direction I have written my lecture, not to undervalue any form of scientific labor in its place, an unworthy thought from which I hope I need not defend myself,—but to discourage any undue inflation of the scholastic programme, which even now asks more of the student than the teacher is able to obtain from the great majority of those who present themselves for examination. I wish to take a hint in education from the Secretary of the Massachusetts Board of Agriculture, who regards the cultivation of too much land as a great defect in our New England farming. I hope that our Medical Institutions may never lay themselves open to the kind of accusation Mr. Lowe brings against the English Universities, when he says that their education is made up "of words that few understand and most will shortly forget; of arts that can never be used, if indeed they can even be learnt; of histories inapplicable to our times; of languages dead and even mouldy; of grammatical rules that never had living use and are only post mortem examinations; and of statements fagoted with utter disregard of their comparative value."
This general thought will be kept in view throughout my somewhat discursive address, which will begin with an imaginary clinical lesson from the lips of an historical personage, and close with the portrait from real life of one who, both as teacher and practitioner, was long loved and honored among us. If I somewhat overrun my hour, you must pardon me, for I can say with Pascal that I have not had the time to make my lecture shorter.
In the year 1647, that good man John Eliot, commonly called the Apostle Eliot, writing to Mr. Thomas Shepherd, the pious minister of Cambridge, referring to the great need of medical instruction for the Indians, used these words:
"I have thought in my heart that it were a singular good work, if the Lord would stirre up the hearts of some or other of his people in England to give some maintenance toward some Schoole or Collegiate exercise this way, wherein there should be Anatomies and other instructions that way, and where there might be some recompence given to any that should bring in any vegetable or other thing that is vertuous in the way of Physick.
"There is another reason which moves my thought and desires this way, namely that our young students in Physick may be trained up better then they yet bee, who have onely theoreticall knowledge, and are forced to fall to practise before ever they saw an Anatomy made, or duely trained up in making experiments, for we never had but one Anatomy in the countrey, which Mr. Giles Firman [Firmin] now in England, did make and read upon very well, but no more of that now."
Since the time of the Apostle Eliot the Lord has stirred up the hearts of our people to the building of many Schools and Colleges where medicine is taught in all its branches. Mr. Giles Firmin's "Anatomy" may be considered the first ancestor of a long line of skeletons which have been dangling and rattling in our lecture-rooms for more than a century.
Teaching in New England in 1647 was a grave but simple matter. A single person, combining in many cases, as in that of Mr. Giles Firmin, the offices of physician and preacher, taught what he knew to a few disciples whom he gathered about him. Of the making of that "Anatomy" on which my first predecessor in the branch I teach "did read very well" we can know nothing. The body of some poor wretch who had swung upon the gallows, was probably conveyed by night to some lonely dwelling at the outskirts of the village, and there by the light of flaring torches hastily dissected by hands that trembled over the unwonted task. And ever and anon the master turned to his book, as he laid bare the mysteries of the hidden organs; to his precious Vesalius, it might be, or his figures repeated in the multifarious volume of Ambroise Pare; to the Aldine octavo in which Fallopius recorded his fresh observations; or that giant folio of Spigelius just issued from the press of Amsterdam, in which lovely ladies display their viscera with a coquettish grace implying that it is rather a pleasure than otherwise to show the lace-like omentum, and hold up their appendices epiploicae as if they were saying "these are our jewels."
His teaching of medicine was no doubt chiefly clinical, and received with the same kind of faith as that which accepted his words from the pulpit. His notions of disease were based on what he had observed, seen always in the light of the traditional doctrines in which he was bred. His discourse savored of the weighty doctrines of Hippocrates, diluted by the subtle speculations of Galen, reinforced by the curious comments of the Arabian schoolmen as they were conveyed in the mellifluous language of Fernelius, blended, it may be, with something of the lofty mysticism of Van Helmont, and perhaps stealing a flavor of that earlier form of Homoeopathy which had lately come to light in Sir Kenelm Digby's "Discourse concerning the Cure of Wounds by the Sympathetic Powder."
His Pathology was mythology. A malformed foetus, as the readers of Winthrop's Journal may remember, was enough to scare the colonists from their propriety, and suggest the gravest fears of portended disaster. The student of the seventeenth century opened his Licetus and saw figures of a lion with the head of a woman, and a man with the head of an elephant. He had offered to his gaze, as born of a human mother, the effigy of a winged cherub, a pterocephalous specimen, which our Professor of Pathological Anatomy would hardly know whether to treat with the reverence due to its celestial aspect, or to imprison in one of his immortalizing jars of alcohol.
His pharmacopoeia consisted mainly of simples, such as the venerable "Herball" of Gerard describes and figures in abounding affluence. St. John's wort and Clown's All-heal, with Spurge and Fennel, Saffron and Parsley, Elder and Snake-root, with opium in some form, and roasted rhubarb and the Four Great Cold Seeds, and the two Resins, of which it used to be said that whatever the Tacamahaca has not cured, the Caranna will, with the more familiar Scammony and Jalap and Black Hellebore, made up a good part of his probable list of remedies. He would have ordered Iron now and then, and possibly an occasional dose of Antimony. He would perhaps have had a rheumatic patient wrapped in the skin of a wolf or a wild cat, and in case of a malignant fever with "purples" or petechiae, or of an obstinate king's evil, he might have prescribed a certain black powder, which had been made by calcining toads in an earthen pot; a choice remedy, taken internally, or applied to any outward grief.
Except for the toad-powder and the peremptory drastics, one might have borne up against this herb doctoring as well as against some more modern styles of medication. Barbeyrac and his scholar Sydenham had not yet cleansed the Pharmacopoeia of its perilous stuff, but there is no doubt that the more sensible physicians of that day knew well enough that a good honest herb-tea which amused the patient and his nurses was all that was required to carry him through all common disorders.
The student soon learned the physiognomy of disease by going about with his master; fevers, pleurisies, asthmas, dropsies, fluxes, small-pox, sore-throats, measles, consumptions. He saw what was done for them. He put up the medicines, gathered the herbs, and so learned something of materia medico and botany. He learned these few things easily and well, for he could give his whole attention to them. Chirurgery was a separate specialty. Women in child-birth were cared for by midwives. There was no chemistry deserving the name to require his study. He did not learn a great deal, perhaps, but what he did learn was his business, namely, how to take care of sick people.
Let me give you a picture of the old=fashioned way of instruction, by carrying you with me in imagination in the company of worthy Master Giles Firmin as he makes his round of visits among the good folk of Ipswich, followed by his one student, who shall answer to the scriptural name of Luke. It will not be for entertainment chiefly, but to illustrate the one mode of teaching which can never be superseded, and which, I venture to say, is more important than all the rest put together. The student is a green hand, as you will perceive.
In the first dwelling they come to, a stout fellow is bellowing with colic.
"He will die, Master, of a surety, methinks," says the timid youth in a whisper.
"Nay, Luke," the Master answers, "'t is but a dry belly-ache. Didst thou not mark that he stayed his roaring when I did press hard over the lesser bowels? Note that he hath not the pulse of them with fevers, and by what Dorcas telleth me there hath been no long shutting up of the vice naturales. We will steep certain comforting herbs which I will shew thee, and put them in a bag and lay them on his belly. Likewise he shall have my cordial julep with a portion of this confection which we do call Theriaca Andromachi, which hath juice of poppy in it, and is a great stayer of anguish. This fellow is at his prayers to-day, but I warrant thee he shall be swearing with the best of them to-morrow."
They jog along the bridle-path on their horses until they come to another lowly dwelling. They sit a while with a delicate looking girl in whom the ingenuous youth naturally takes a special interest. The good physician talks cheerfully with her, asks her a few questions. Then to her mother: "Good-wife, Margaret hath somewhat profited, as she telleth, by the goat's milk she hath taken night and morning. Do thou pluck a maniple—that is an handful—of the plant called Maidenhair, and make a syrup therewith as I have shewed thee. Let her take a cup full of the same, fasting, before she sleepeth, also before she riseth from her bed." And so they leave the house.
"What thinkest thou, Luke, of the maid we have been visiting?" "She seemeth not much ailing, Master, according to my poor judgment. For she did say she was better. And she had a red cheek and a bright eye, and she spake of being soon able to walk unto the meeting, and did seem greatly hopeful, but spare of flesh, methought, and her voice something hoarse, as of one that hath a defluxion, with some small coughing from a cold, as she did say. Speak I not truly, Master, that she will be well speedily?"
"Yea, Luke, I do think she shall be well, and mayhap speedily. But it is not here with us she shall be well. For that redness of the cheek is but the sign of the fever which, after the Grecians, we do call the hectical; and that shining of the eyes is but a sickly glazing, and they which do every day get better and likewise thinner and weaker shall find that way leadeth to the church-yard gate. This is the malady which the ancients did call tubes, or the wasting disease, and some do name the consumption. A disease whereof most that fall ailing do perish. This Margaret is not long for earth—but she knoweth it not, and still hopeth."
"Why, then, Master, didst thou give her of thy medicine, seeing that her ail is unto death?"
"Thou shalt learn, boy, that they which are sick must have somewhat wherewith to busy their thoughts. There be some who do give these tabid or consumptives a certain posset made with lime-water and anise and liquorice and raisins of the sun, and there be other some who do give the juice of craw-fishes boiled in barley-water with chicken-broth, but these be toys, as I do think, and ye shall find as good virtue, nay better, in this syrup of the simple called Maidenhair."
Something after this manner might Master Giles Firmin have delivered his clinical instructions. Somewhat in this way, a century and a half later, another New England physician, Dr. Edward Augustus Holyoke, taught a young man who came to study with him, a very diligent and intelligent youth, James Jackson by name, the same whose portrait in his advanced years hangs upon this wall, long the honored Professor of Theory and Practice in this Institution, of whom I shall say something in this Lecture. Our venerated Teacher studied assiduously afterwards in the great London Hospitals, but I think he used to quote his "old Master" ten times where he quoted Mr. Cline or Dr. Woodville once.
When I compare this direct transfer of the practical experience of a wise man into the mind of a student,—every fact one that he can use in the battle of life and death,—with the far off, unserviceable "scientific" truths that I and some others are in the habit of teaching, I cannot help asking myself whether, if we concede that our forefathers taught too little, there is not—a possibility that we may sometimes attempt to teach too much. I almost blush when I think of myself as describing the eight several facets on two slender processes of the palate bone, or the seven little twigs that branch off from the minute tympanic nerve, and I wonder whether my excellent colleague feels in the same way when he pictures himself as giving the constitution of neurin, which as he and I know very well is that of the hydrate of trimethyle-oxethyle-ammonium, or the formula for the production of alloxan, which, though none but the Professors and older students can be expected to remember it, is C10 H4 N4 O6+ 2HO, NO5=C8 H4 N2 O10+2CO2+N2+NH4 O, NO5.
I can bear the voice of some rough iconoclast addressing the Anatomist and the Chemist in tones of contemptuous indignation: "What is this stuff with which you are cramming the brains of young men who are to hold the lives of the community in their hands? Here is a man fallen in a fit; you can tell me all about the eight surfaces of the two processes of the palate bone, but you have not had the sense to loosen that man's neck-cloth, and the old women are all calling you a fool? Here is a fellow that has just swallowed poison. I want something to turn his stomach inside out at the shortest notice. Oh, you have forgotten the dose of the sulphate of zinc, but you remember the formula for the production of alloxan!"
"Look you, Master Doctor,—if I go to a carpenter to come and stop a leak in my roof that is flooding the house, do you suppose I care whether he is a botanist or not? Cannot a man work in wood without knowing all about endogens and exogens, or must he attend Professor Gray's Lectures before he can be trusted to make a box-trap? If my horse casts a shoe, do you think I will not trust a blacksmith to shoe him until I have made sure that he is sound on the distinction between the sesquioxide and the protosesquioxide of iron?"
—But my scientific labor is to lead to useful results by and by, in the next generation, or in some possible remote future.—
"Diavolo!" as your Dr. Rabelais has it,—answers the iconoclast,—"what is that to me and my colic, to me and my strangury? I pay the Captain of the Cunard steamship to carry me quickly and safely to Liverpool, not to make a chart of the Atlantic for after voyagers! If Professor Peirce undertakes to pilot me into Boston Harbor and runs me on Cohasset rocks, what answer is it to tell me that he is Superintendent of the Coast Survey? No, Sir! I want a plain man in a pea-jacket and a sou'wester, who knows the channel of Boston Harbor, and the rocks of Boston Harbor, and the distinguished Professor is quite of my mind as to the matter, for I took the pains to ask him before I ventured to use his name in the way of illustration."
I do not know how the remarks of the image-breaker may strike others, but I feel that they put me on my defence with regard to much of my teaching. Some years ago I ventured to show in an introductory Lecture how very small a proportion of the anatomical facts taught in a regular course, as delivered by myself and others, had any practical bearing whatever on the treatment of disease. How can I, how can any medical teacher justify himself in teaching anything that is not like to be of practical use to a class of young men who are to hold in their hands the balance in which life and death, ease and anguish, happiness and wretchedness are to be daily weighed?
I hope we are not all wrong. Oftentimes in finding how sadly ignorant of really essential and vital facts and rules were some of those whom we had been larding with the choicest scraps of science, I have doubted whether the old one-man system of teaching, when the one man was of the right sort, did not turn out better working physicians than our more elaborate method. The best practitioner I ever knew was mainly shaped to excellence in that way. I can understand perfectly the regrets of my friend Dr. John Brown of Edinburgh, for the good that was lost with the old apprenticeship system. I understand as well Dr. Latham's fear "that many men of the best abilities and good education will be deterred from prosecuting physic as a profession, in consequence of the necessity indiscriminately laid upon all for impossible attainments."
I feel therefore impelled to say a very few words in defence of that system of teaching adopted in our Colleges, by which we wish to supplement and complete the instruction given by private individuals or by what are often called Summer Schools.
The reason why we teach so much that is not practical and in itself useful, is because we find that the easiest way of teaching what is practical and useful. If we could in any way eliminate all that would help a man to deal successfully with disease, and teach it by itself so that it should be as tenaciously rooted in the memory, as easily summoned when wanted, as fertile in suggestion of related facts, as satisfactory to the peremptory demands of the intelligence as if taught in its scientific connections, I think it would be our duty so to teach the momentous truths of medicine, and to regard all useless additions as an intrusion on the time which should be otherwise occupied.
But we cannot successfully eliminate and teach by itself that which is purely practical. The easiest and surest why of acquiring facts is to learn them in groups, in systems, and systematized knowledge is science. You can very often carry two facts fastened together more easily than one by itself, as a housemaid can carry two pails of water with a hoop more easily than one without it. You can remember a man's face, made up of many features, better than you can his nose or his mouth or his eye-brow. Scores of proverbs show you that you can remember two lines that rhyme better than one without the jingle. The ancients, who knew the laws of memory, grouped the seven cities that contended for the honor of being Homer's birthplace in a line thus given by Aulus Gellius:
Smurna, Rodos, Colophon, Salamin, Ios, Argos, Athenai.
I remember, in the earlier political days of Martin Van Buren, that Colonel Stone, of the "New York Commercial," or one of his correspondents, said that six towns of New York would claim in the same way to have been the birth-place of the "Little Magician," as he was then called; and thus he gave their names, any one of which I should long ago have forgotten, but which as a group have stuck tight in my memory from that day to this;
Catskill, Saugerties, Redhook, Kinderhook, Scaghticoke, Schodac.
If the memory gains so much by mere rhythmical association, how much more will it gain when isolated facts are brought together under laws and principles, when organs are examined in their natural connections, when structure is coupled with function, and healthy and diseased action are studied as they pass one into the other! Systematic, or scientific study is invaluable as supplying a natural kind of mnemonics, if for nothing else. You cannot properly learn the facts you want from Anatomy and Chemistry in any way so easily as by taking them in their regular order, with other allied facts, only there must be common sense exercised in leaving out a great deal which belongs to each of the two branches as pure science. The dullest of teachers is the one who does not know what to omit.
The larger aim of scientific training is to furnish you with principles to which you will be able to refer isolated facts, and so bring these within the range of recorded experience. See what the "London Times" said about the three Germans who cracked open John Bull Chatwood's strong-box at the Fair the other day, while the three Englishmen hammered away in vain at Brother Jonathan Herring's. The Englishmen represented brute force. The Germans had been trained to appreciate principle. The Englishman "knows his business by rote and rule of thumb"—science, which would "teach him to do in an hour what has hitherto occupied him two hours," "is in a manner forbidden to him." To this cause the "Times" attributes the falling off of English workmen in comparison with those of the Continent.
Granting all this, we must not expect too much from "science" as distinguished from common experience. There are ten thousand experimenters without special apparatus for every one in the laboratory. Accident is the great chemist and toxicologist. Battle is the great vivisector. Hunger has instituted researches on food such as no Liebig, no Academic Commission has ever recorded.
Medicine, sometimes impertinently, often ignorantly, often carelessly called "allopathy," appropriates everything from every source that can be of the slightest use to anybody who is ailing in any way, or like to be ailing from any cause. It learned from a monk how to use antimony, from a Jesuit how to cure agues, from a friar how to cut for stone, from a soldier how to treat gout, from a sailor how to keep off scurvy, from a postmaster how to sound the Eustachian tube, from a dairy-maid how to prevent small-pox, and from an old market-woman how to catch the itch-insect. It borrowed acupuncture and the moxa from the Japanese heathen, and was taught the use of lobelia by the American savage. It stands ready to-day to accept anything from any theorist, from any empiric who can make out a good case for his discovery or his remedy. "Science" is one of its benefactors, but only one, out of many. Ask the wisest practising physician you know, what branches of science help him habitually, and what amount of knowledge relating to each branch he requires for his professional duties. He will tell you that scientific training has a value independent of all the special knowledge acquired. He will tell you that many facts are explained by studying them in the wider range of related facts to which they belong. He will gratefully recognize that the anatomist has furnished him with indispensable data, that the physiologist has sometimes put him on the track of new modes of treatment, that the chemist has isolated the active principles of his medicines, has taught him how to combine them, has from time to time offered him new remedial agencies, and so of others of his allies. But he will also tell you, if I am not mistaken, that his own branch of knowledge is so extensive and so perplexing that he must accept most of his facts ready made at their hands. He will own to you that in the struggle for life which goes on day and night in our thoughts as in the outside world of nature, much that he learned under the name of science has died out, and that simple homely experience has largely taken the place of that scholastic knowledge to which he and perhaps some of his instructors once attached a paremount importance.
This, then, is my view of scientific training as conducted in courses such as you are entering on. Up to a certain point I believe in set Lectures as excellent adjuncts to what is far more important, practical instruction at the bedside, in the operating room, and under the eye of the Demonstrator. But I am so far from wishing these courses extended, that I think some of them—suppose I say my own—would almost bear curtailing. Do you want me to describe more branches of the sciatic and crural nerves? I can take Fischer's plates, and lecturing on that scale fill up my whole course and not finish the nerves alone. We must stop somewhere, and for my own part I think the scholastic exercises of our colleges have already claimed their full share of the student's time without our seeking to extend them.
I trust I have vindicated the apparent inconsequence of teaching young students a good deal that seems at first sight profitless, but which helps them to learn and retain what is profitable. But this is an inquisitive age, and if we insist on piling up beyond a certain height knowledge which is in itself mere trash and lumber to a man whose life is to be one long fight with death and disease, there will be some sharp questions asked by and by, and our quick-witted people will perhaps find they can get along as well without the professor's cap as without the bishop's mitre and the monarch's crown.
I myself have nothing to do with clinical teaching. Yet I do not hesitate to say it is more essential than all the rest put together, so far as the ordinary practice of medicine is concerned; and this is by far the most important thing to be learned, because it deals with so many more lives than any other branch of the profession. So of personal instruction, such as we give and others give in the interval of lectures, much of it at the bedside, some of it in the laboratory, some in the microscope-room, some in the recitation-room, I think it has many advantages of its own over the winter course, and I do not wish to see it shortened for the sake of prolonging what seems to me long enough already.
If I am jealous of the tendency to expand the time given to the acquisition of curious knowledge, at the expense of the plain old-fashioned bedside teachings, I only share the feeling which Sydenham expressed two hundred years ago, using an image I have already borrowed. "He would be no honest and successful pilot who was to apply himself with less industry to avoid rocks and sands and bring his vessel safely home, than to search into the causes of the ebbing and flowing of the sea, which, though very well for a philosopher, is foreign to him whose business it is to secure the ship. So neither will a physician, whose province it is to cure diseases, be able to do so, though he be a person of great genius, who bestows less time on the hidden and intricate method of nature, and adapting his means thereto, than on curious and subtle speculation."
"Medicine is my wife and Science is my mistress," said Dr. Rush. I do not think that the breach of the seventh commandment can be shown to have been of advantage to the legitimate owner of his affections. Read what Dr. Elisha Bartlett says of him as a practitioner, or ask one of our own honored ex-professors, who studied under him, whether Dr. Rush had ever learned the meaning of that saying of Lord Bacon, that man is the minister and interpreter of Nature, or whether he did not speak habitually of Nature as an intruder in the sick room, from which his art was to expel her as an incompetent and a meddler.
All a man's powers are not too much for such a profession as Medicine. "He is a learned man," said old Parson Emmons of Franklin, "who understands one subject, and he is a very learned man who understands two subjects." Schonbein says he has been studying oxygen for thirty years. Mitscherlich said it took fourteen years to establish a new fact in chemistry. Aubrey says of Harvey, the discoverer of the circulation, that "though all his profession would allow him to be an excellent anatomist, I have never heard of any who admired his therapeutic way." My learned and excellent friend before referred to, Dr. Brown of Edinburgh, from whose very lively and sensible Essay, "Locke and Sydenham," I have borrowed several of my citations, contrasts Sir Charles Bell, the discoverer, the man of science, with Dr. Abercrombie, the master in the diagnosis and treatment of disease. It is through one of the rarest of combinations that we have in our Faculty a teacher on whom the scientific mantle of Bell has fallen, and who yet stands preeminent in the practical treatment of the class of diseases which his inventive and ardent experimental genius has illustrated. M. Brown-Sequard's example is as, eloquent as his teaching in proof of the advantages of well directed scientific investigation. But those who emulate his success at once as a discoverer and a practitioner must be content like him to limit their field of practice. The highest genius cannot afford in our time to forget the ancient precept, Divide et impera.
"I suppose I must go and earn this guinea," said a medical man who was sent for while he was dissecting an animal. I should not have cared to be his patient. His dissection would do me no good, and his thoughts would be too much upon it. I want a whole man for my doctor, not a half one. I would have sent for a humbler practitioner, who would have given himself entirely to me, and told the other—who was no less a man than John Hunter—to go on and finish the dissection of his tiger.
Sydenham's "Read Don Quixote" should be addressed not to the student, but to the Professor of today. Aimed at him it means, "Do not be too learned."
Do not think you are going to lecture to picked young men who are training themselves to be scientific discoverers. They are of fair average capacity, and they are going to be working doctors.
These young men are to have some very serious vital facts to deal with.
I will mention a few of them.
Every other resident adult you meet in these streets is or will be more or less tuberculous. This is not an extravagant estimate, as very nearly one third of the deaths of adults in Boston last year were from phthisis. If the relative number is less in our other northern cities, it is probably in a great measure because they are more unhealthy; that is, they have as much, or nearly as much, consumption, but they have more fevers or other fatal diseases.
These heavy-eyed men with the alcoholized brains, these pallid youths with the nicotized optic ganglia and thinking-marrows brown as their own meerschaums, of whom you meet too many,—will ask all your wisdom to deal with their poisoned nerves and their enfeebled wills.
Nearly seventeen hundred children under five years of age died last year in this city. A poor human article, no doubt, in many cases, still, worth an attempt to save them, especially when we remember the effect of Dr. Clarke's suggestion at the Dublin Hospital, by which some twenty-five or thirty thousand children's lives have probably been saved in a single city.
Again, the complaint is often heard that the native population is not increasing so rapidly as in former generations. The breeding and nursing period of American women is one of peculiar delicacy and frequent infirmity. Many of them must require a considerable interval between the reproductive efforts, to repair damages and regain strength. This matter is not to be decided by an appeal to unschooled nature. It is the same question as that of the deformed pelvis,—one of degree. The facts of mal-vitalization are as much to be attended to as those of mal-formation. If the woman with a twisted pelvis is to be considered an exempt, the woman with a defective organization should be recognized as belonging to the invalid corps. We shudder to hear what is alleged as to the prevalence of criminal practices; if back of these there can be shown organic incapacity or overtaxing of too limited powers, the facts belong to the province of the practical physician, as well as of the moralist and the legislator, and require his gravest consideration.
Take the important question of bleeding. Is venesection done with forever? Six years ago it was said here in an introductory Lecture that it would doubtless come back again sooner or later. A fortnight ago I found myself in the cars with one of the most sensible and esteemed practitioners in New England. He took out his wallet and showed me two lancets, which he carried with him; he had never given up their use. This is a point you will have to consider.
Or, to mention one out of many questionable remedies, shall you give Veratrum Viride in fevers and inflammations? It makes the pulse slower in these affections. Then the presumption would naturally be that it does harm. The caution with reference to it on this ground was long ago recorded in the Lecture above referred to. See what Dr. John Hughes Bennett says of it in the recent edition of his work on Medicine. Nothing but the most careful clinical experience can settle this and such points of treatment.
These are all practical questions—questions of life and death, and every day will be full of just such questions. Take the problem of climate. A patient comes to you with asthma and wants to know where he can breathe; another comes to you with phthisis and wants to know where he can live. What boy's play is nine tenths of all that is taught in many a pretentious course of lectures, compared with what an accurate and extensive knowledge of the advantages and disadvantages of different residences in these and other complaints would be to a practising physician.
I saw the other day a gentleman living in Canada, who had spent seven successive winters in Egypt, with the entire relief of certain obscure thoracic symptoms which troubled him while at home. I saw, two months ago, another gentleman from Minnesota, an observer and a man of sense, who considered that State as the great sanatorium for all pulmonary complaints. If half our grown population are or will be more or less tuberculous, the question of colonizing Florida assumes a new aspect. Even within the borders of our own State, the very interesting researches of Dr. Bowditch show that there is a great variation in the amount of tuberculous disease in different towns, apparently connected with local conditions. The hygienic map of a State is quite as valuable as its geological map, and it is the business of every practising physician to know it thoroughly. They understand this in England, and send a patient with a dry irritating cough to Torquay or Penzance, while they send another with relaxed bronchial membranes to Clifton or Brighton. Here is another great field for practical study.
So as to the all-important question of diet. "Of all the means of cure at our command," says Dr. Bennett, "a regulation of the quantity and quality of the diet is by far the most powerful." Dr. MacCormac would perhaps except the air we breathe, for he thinks that impure air, especially in sleeping rooms, is the great cause of tubercle. It is sufficiently proved that the American,—the New Englander,—the Bostonian, can breed strong and sound children, generation after generation,—nay, I have shown by the record of a particular family that vital losses may be retrieved, and a feeble race grow to lusty vigor in this very climate and locality. Is not the question why our young men and women so often break down, and how they can be kept from breaking down, far more important for physicians to settle than whether there is one cranial vertebra, or whether there are four, or none?
—But I have a taste for the homologies, I want to go deeply into the subject of embryology, I want to analyze the protonihilates precipitated from pigeon's milk by the action of the lunar spectrum,—shall I not follow my star,—shall I not obey my instinct,—shall I not give myself to the lofty pursuits of science for its own sake?
Certainly you may, if you like. But take down your sign, or never put it up. That is the way Dr. Owen and Dr. Huxley, Dr. Agassiz and Dr. Jeffries Wyman, Dr. Gray and Dr. Charles T. Jackson settled the difficulty. We all admire the achievements of this band of distinguished doctors who do not practise. But we say of their work and of all pure science, as the French officer said of the charge of the six hundred at Balaclava, "C'est magnifique, mais ce n'est pas la guerre,"—it is very splendid, but it is not a practising doctor's business. His patient has a right to the cream of his life and not merely to the thin milk that is left after "science" has skimmed it off. The best a physician can give is never too good for the patient.
It is often a disadvantage to a young practitioner to be known for any accomplishment outside of his profession. Haller lost his election as Physician to the Hospital in his native city of Berne, principally on the ground that he was a poet. In his later years the physician may venture more boldly. Astruc was sixty-nine years old when he published his "Conjectures," the first attempt, we are told, to decide the authorship of the Pentateuch showing anything like a discerning criticism. Sir Benjamin Brodie was seventy years old before he left his physiological and surgical studies to indulge in psychological speculations. The period of pupilage will be busy enough in acquiring the knowledge needed, and the season of active practice will leave little leisure for any but professional studies.
Dr. Graves of Dublin, one of the first clinical teachers of our time, always insisted on his students' beginning at once to visit the hospital. At the bedside the student must learn to treat disease, and just as certainly as we spin out and multiply our academic prelections we shall work in more and more stuffing, more and more rubbish, more and more irrelevant, useless detail which the student will get rid of just as soon as he leaves us. Then the next thing will be a new organization, with an examining board of first-rate practical men, who will ask the candidate questions that mean business,—who will make him operate if he is to be a surgeon, and try him at the bedside if he is to be a physician,—and not puzzle him with scientific conundrums which not more than one of the questioners could answer himself or ever heard of since he graduated.