Chapter 22
“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 way 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 paramount 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.